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As BerryDunn’s Healthcare Practice Group lead, Lisa Trundy-Whitten is closely attuned to the healthcare industry. From challenges faced by healthcare organizations to the solutions BerryDunn’s experts can provide, Lisa shares thoughtful insights for healthcare leaders.  

Today’s healthcare leaders are navigating a perfect storm. Workforce shortages, financial strain, regulatory uncertainty, technology integration challenges, cybersecurity risks, and persistent inequities converge to create unprecedented pressure across the industry. Meanwhile, leaders are being asked to innovate, improve operational efficiencies, and deliver exceptional care—all while remaining compliant and financially viable. 

In this shifting climate, thinking strategically about the key challenges you face is essential, including for: 

  • Financial pressures and reimbursement: Identifying ways to navigate cuts to the Physician Fee Schedule, constrained reimbursement growth, and shifting payer mix 

  • Revenue cycle management: Reviewing the full life cycle of your revenue—from patient access to final payment—and determining where to optimize reimbursement and minimize inefficiencies 

  • Federal and state policy changes: Monitoring the latest developments, such as the impacts of the Inflation Reduction Act, the One Big Beautiful Bill Act (OBBBA), and new payment models 

  • Compliance and credentialing: Staying compliant with evolving standards is a constant challenge, especially for organizations expanding into new markets or service lines for financial sustainability 

  • Reducing costs and improving efficiency: Seeking creative approaches to service delivery, leveraging teams, and adopting digital solutions to streamline operations 

  • AI adoption: Employing AI for operational efficiency, predictive analytics, and member advocacy while balancing concerns about cost, governance, and compliance 

As healthcare leaders, you grapple with these concerns daily. And even though the issues are familiar, the urgency is new. The key to staying viable is investing in innovation and collaboration and placing a strategic focus on operational efficiency, workforce well-being, and patient-centered care, all while remaining adaptable. 

Considering these pressures, what sets successful organizations apart? 

Recommendations for healthcare leaders 

There are common threads among healthcare organizations that are finding operational success and remaining compliant in today’s fickle environment. These include: 

  • Adaptability 

  • Willingness to explore new ideas 

  • Ability to anticipate change 

  • Commitment to data-driven decision-making 

  • Collaboration across finance, operations, and clinical teams 

Consider assessing how your organization is performing in each of these areas. Can you find ways to pivot by applying innovations and strategic thinking? Are your teams working seamlessly to carry out your strategic vision and drive meaningful results? What guides your operational decisions? Are there areas where seeking external help may benefit your organization? 

For guidance on the latest related to the OBBBA, executive orders, and other federal and judicial actions impacting the healthcare industry in both the short- and long-term, we encourage you to download this full summary created by BerryDunn’s industry experts. The summary outlines topics, including key provisions, potential impacts, and important dates.  

You can count on us to keep you abreast of the latest changes through updates to our summary and timely communications, as with the recent shift in application deadline for the Rural Health Transformation Program from December 31 to November 5 announced in September. Look to our healthcare team to provide educational opportunities and key industry insights to empower you to uncover actionable strategies for improving operational efficiencies. 

Our dedicated team of experts meets regularly to track the latest developments affecting healthcare. We recommend routinely visiting the BerryDunn website for the latest insights from our industry thought leaders. 

We’re here for you 

BerryDunn’s Healthcare Practice Group has unmatched depth and breadth of services that truly span the healthcare continuum. Our areas of expertise are focused on helping organizations by providing financial, health IT, revenue cycle, and compliance consulting, as well as offering research and data analytics, coding and OASIS services, and home health training and education. 

Our expert advisors deliver practical, up-to-date advice to improve your performance and can help with issues like high taxes, financial and regulatory compliance, cash flow constraints, leadership transitions, evolving technology needs, and workforce development gaps.    

I encourage you to learn more about our services and team and reach out to us to start a conversation on how BerryDunn can support and guide you toward sustainability and compliance. Let’s work together to create a strategy that fits your unique needs. 

We're here for you. 

Best,  

Lisa Trundy-Whitten 

Article
Navigating a perfect storm: Strategic insights for today's healthcare leaders

In a move that has sparked widespread attention across higher education, the US Department of Education (ED) recently placed Harvard University on Heightened Cash Monitoring (HCM) status. This designation is typically reserved for institutions facing serious financial or administrative challenges. While Harvard’s inclusion may come as a surprise, the decision underscores the importance of understanding the HCM framework and its implications for colleges and universities nationwide. 

What is Heightened Cash Monitoring (HCM)?

HCM is a regulatory mechanism used by ED to increase oversight of institutions participating in federal Title IV financial aid programs. There are two levels of HCM: 

  • HCM1: Institutions must disburse federal aid to students using their own funds first, then submit disbursement records to ED. 
  • HCM2: A more stringent level, requiring institutions to submit detailed documentation for each student before receiving reimbursement. This includes student eligibility, disbursement records, and confirmation of credit balance payments. 

Institutions may be placed on HCM due to concerns about financial responsibility, administrative capability, audit findings, accreditation issues, or other compliance problems. The goal is to monitor institutions to determine whether federal student aid is awarded and disbursed appropriately.  

When an institution is placed under HCM, institutions can be faced with operational burdens such as: 

  • Using institutional funds to cover federal aid disbursements upfront 
  • Experiencing delays in being reimbursed for the federal disbursements covered with operational funds 
  • Posting a letter of credit as financial collateral may be required 
  • Undergoing increased scrutiny from ED, including periodic reviews and documentation audits 

These requirements can impact student services, financial aid processing, and institutional reputation. 

To be removed from HCM, institutions must: 

  • Resolve the underlying issues by taking actions such as submitting overdue audits, improving financial metrics, or addressing compliance violations. 
  • Demonstrate sustained compliance with Title IV regulations. 
  • Maintain transparent and timely reporting to ED. 
  • In some cases, undergo a probationary period before full reinstatement to the advance payment method. 

The process is rigorous and can take months or even years, depending on the severity of the issues. 

How higher ed institutions can mitigate the risk of HCM

HCM is a powerful tool for federal oversight, designed to apply accountability and protect public funds. While some have questioned the rationale behind Harvard’s HCM designation, the broader framework of HCM remains a key component of ED’s oversight. The following are key areas where institutions can focus and take proactive steps to mitigate their risk of HCM designation:

1. Maintain strong financial health
Institutions should prioritize maintaining a Federal Financial Responsibility Composite Score above 1.5, as calculated by ED. This score reflects the overall financial health of an institution and is a key indicator used in HCM evaluations. Institutions should also avoid taking on excessive long-term borrowings without clear repayment strategies and maintain long-term borrowing levels relative to an institution’s revenue streams. Additionally, institutions should make certain of accurate and timely filings of their audited financial statements.

2. Maintain effective administrative operations
Operational efficiency and regulatory compliance go hand in hand. Institutions should provide adequate training to all financial aid staff members, avoid turnover in key financial aid positions, and promptly address any audit findings. Delays in disbursement or reconciliation of federal funds can trigger red flags during ED reviews. Investing in robust administrative systems and staff training can help institutions stay ahead of potential issues.

3. Monitor compliance and risk indicators
Institutions should conduct regular internal reviews of Title IV funds, including policies and procedures to address compliance with all federal regulations. Institutions should respond promptly to inquiries from the Federal Government. Maintaining good standing with accrediting bodies not only supports eligibility for federal aid but also signals institutional integrity to students and the public.

Strategic Insights for higher education institutions

BerryDunn offers a wide range of assurance and consulting services to meet the specific needs of higher education institutions. We focus on building strong client relationships that stand the test of time, helping colleges and universities minimize risk and maximize efficiencies. Learn more about our team and services.

Article
Understanding Heightened Cash Monitoring: Implications for Colleges and Universities

Assuring access to behavioral health services in rural communities remains one of the most persistent and critical challenges that state governments face today. Research shows that nearly 18% of large rural areas and over 40% of small or isolated rural areas are at least 30 minutes away from any mental health care facility. In comparison, fewer than 10% of urban areas face this issue. According to Rural Health Information Hub, over 70% of rural counties lack a psychiatrist, and many have no psychologists or licensed counselors. Rural communities often struggle to access behavioral health services, which can harm community well-being, economic stability, and family life. 

Most rural communities also lack reliable public transportation, which makes it difficult for people without personal vehicles to access behavioral health services and support. Even for those with personal vehicles, costs related to fuel, insurance, and vehicle maintenance can be prohibitive for low-income households. Based on our experience and observations in rural communities, many people rely on family and friends for rides, which can be an inconsistent resource and may compromise privacy or people’s willingness to access services.  

Many individuals in rural communities are also unaware of treatment options or where to seek behavioral health services and support. Behavioral health services are often poorly advertised. In addition, our experience shows that rural communities tend to prefer receiving information through word of mouth, relying on trusted neighbors, friends, and local leaders to share news about available services. 

Misconceptions about behavioral health services persist in many rural communities and in small communities where “everyone knows everyone.” Based on our experience, people may avoid seeking help due to stigma around mental health and fear of being judged, especially when behavioral health services are visibly located within the community. Rural culture often emphasizes self-reliance, which can discourage help-seeking behavior and reinforces the belief that mental health challenges should be managed privately.  

The areas below highlight essential steps to help promote access, strengthen collaboration, and increase awareness of behavioral health services in rural communities. 

Expand transportation access 

Transportation is a critical barrier for many rural residents. To help expand transportation access, consider the following: 

  • Add or increase reimbursement rates for transportation providers to incentivize them to operate in rural communities. 
  • Research and stay apprised of any new funding sources (e.g., Rural Health Information Hub) to support expanded transportation options.  
  • Partner with local transit agencies, non-profits, and community organizations to coordinate rideshare programs, volunteer driver networks, or shuttle services tailored to behavioral health appointments. 

Expanding transportation services—whether through partnerships, subsidies, or new infrastructure—can significantly improve access to care and support. 

Improve how information is shared 

Clear and consistent communication is essential to increase awareness of available behavioral health services and begin to destigmatize mental health treatment. To help improve information dissemination, consider the following: 

  • Establish or reinforce partnerships with local and national organizations and advocacy groups to develop a communication plan and design and implement effective awareness campaigns that inform the public of available behavioral health services.  
  • Partner with trusted local leaders (e.g., faith leader, fire marshal, sheriff) to help deliver messages that challenge mental health stigma and promote accessing services.  
  • Host town halls and/or community forums to address concerns about behavioral health facilities and services.  
  • Establish and actively manage a centralized inbox where rural community members can submit questions, concerns, or feedback about behavioral health services. Ensure timely responses and track recurring themes to inform outreach and service improvements. 
  • Share data and success stories about how behavioral health services improve community well-being, reduce usage of emergency services, and support economic stability.  
  • Be transparent about safety protocols, service populations, and facility operations in rural communities to counter misinformation.   

Through these partnerships, states can help ensure that rural community members are informed of available resources and begin to destigmatize mental health. 

Create a centralized and accessible resource directory 

Developing an electronic directory of available behavioral health programs and services can help people in rural communities easily find the support they need and increase participation in behavioral health. To help people access the services they need, consider the following: 

  • Develop a single, multilingual, and ADA-compliant directory of available programs and services, including crisis lines, outpatient clinics, telehealth options, peer support, and culturally-specific services.  
  • Distribute the directory both online and as paper copies in accessible places such as libraries, clinics, hospitals, schools, churches, food banks, and community centers to reach a wider audience.  
  • Include eligibility criteria, hours of operation, and contact information for each service to reduce confusion and increase follow-through. 
  • Update the directory regularly and include a feedback mechanism, so users can report outdated information or suggest new resources. 
  • Promote the directory through local media, social networks, and community events to raise awareness and encourage use. 
  • Partner with local organizations and leaders to co-brand and distribute the directory, increasing trust and credibility within the community. 
  • Aim to make the directory easy to navigate and accessible to all. 

At BerryDunn, our State Government Practice Group has a proven record of helping clients overcome these barriers. We combine robust data analysis, strategic assessment, and stakeholder engagement to deliver tailored, actionable recommendations that drive measurable improvements. Our experts have guided multiple states through the design and implementation of initiatives that help expand access and support improved outcomes. Contact our behavioral health consulting team to discover how we can partner with you to ensure healthier, more resilient rural communities.   

Article
Bridging the gap: improving behavioral health services in rural communities

When you hear the word “policies,” does it fill you with exhilaration and joy? No? Well, if unbridled enthusiasm isn’t your initial response, then I hope you will benefit from an increased understanding of the purpose and value of well-crafted policies after reading this article.  

Compliance policy doesn’t have a great reputation. We often picture a thick policy and procedures manual in a dusty three-ring binder that might as well be buried in a time capsule given how infrequently they are referenced. But it doesn’t have to be this way! 

Your compliance policies should be living documents that guide daily activities for many staff members. To be effective, they must be clear, concise, and appropriately specific. 

Compliance policy: Find the right balance 

Formal policies and procedures can also vary greatly in how prescriptive they are and in how much actual guidance they provide.  While variety is fine, extremes can be problematic.  

Recently, I was researching a particular policy and looking for good examples. As I dove into the first one, the page numbers flew by—30 pages worth, including verbatim text of federal regulations. Bleary-eyed, I moved on to another example. 

This second one took me a few minutes—and a fair amount of zooming in—to find. Two brief paragraphs. Hmm, did I miss another section somewhere? Nope. This organization decided it wasn’t really necessary to say much of anything about how they would be managing millions of federal dollars. 

What’s the takeaway? While the minimalist approach is concerning, neither example really aligns policy with the actual necessary and compliant activities organizations must perform. 

Policies should NOT be written to cover every possible contingency in explicit long form. Why is that? Because few will read them, and unfortunately, that means even fewer will follow them. A policy manual is ACTUALLY supposed to be read, understood, followed, and frequently referenced. And when a provision should be changed, it can be modified to ensure it is both compliant and accurate. 

Practical guidelines for compliance policy 

  1. Make sure your policy manual is accessible, searchable, and readable: Everyone in the organization needs to be able to understand it. 

  1. Read your existing policy manuals: If that idea makes you cringe, strongly consider modifying your policy because chances are, few are reading it or using it as a reference tool. 

  1. Perform random tests by observing or talking through key processes to determine if policy is being followed: Whether the result is yes or no, figure out the reason(s) behind the answers. It is difficult to improve the policy unless you find out the why. (And remember, just because a policy is being followed, that doesn’t mean it is the best way for the organization to operate.) 

  1. Break up the typical annual policy review by performing a staggered review of individual sections on a rolling basis throughout the year: In this manner, there will be better focus, engagement, and consequently improved results. 

  1. Do you have a policy on policies?: That may sound like an unserious question, but it isn’t. There should be a statement about how your organization writes, handles, and changes its policies. 

Bring pure exhilaration to your organization’s policy manual by continually matching policy to the needs of your organization, not only to stay compliant, but also to operate with the best efficiencies and outcomes. NOTE: Results may vary. You may not experience pure exhilaration, but syncing your policies with your organizational needs is its own reward. 

BerryDunn’s healthcare compliance team incorporates deep, hands-on knowledge with industry best practices to help your organization manage compliance and revenue integrity risks. Learn more about BerryDunn’s team and services. 

Article
Compliance policies: Are we having fun yet?

The FDIC's Quarterly Banking Profile for quarter two 2025 reports the performance for the 3,982 community banks evaluated. Here are the key highlights: 

Note: Graphs are for all FDIC-insured institutions unless the graph indicates it is only for FDIC-insured community banks. 

Financial Performance 

  • Quarterly net income rose by $842.9 million (12.5%) from the previous quarter to $7.6 billion, with 73.4% of community banks reporting an increase. 

  • Pretax return on assets increased to 1.33%, up 15 basis points quarter over quarter and 19 basis points year over year. 

  • Net interest margin rose to 3.62%, up 16 basis points from the prior quarter and 32 basis points year over year.

Costs and Efficiency

  • Noninterest expense increased by $612.7 million (3.5%) from the previous quarter and has increased 6.5% year over year. 

  • Provision expenses increased by 29.2% quarter over quarter and have increased 47.7% year over year, signaling growing concern over potential credit losses. 

  • Efficiency ratio declined to 62.95%, down 75 basis points from the prior quarter, indicating better cost control relative to revenue.

Loan and Deposit Trends 

  • Loan and lease balances increased by $32.3 billion (1.7%) quarter over quarter and 4.9% year over year, led by nonfarm nonresidential CRE and 1–4 family residential loans. 

  • Domestic deposits rose 0.1% quarter over quarter and 2.9% year over year, with stronger growth in noninterest-bearing than interest-bearing accounts. 

  • Nearly three-fourths (73.4%) of community banks reported loan growth, and half reported deposit growth during the quarter. 

Asset Quality

  • Past-due and nonaccrual loans (PDNA) decreased 6 basis points to 1.27%, mainly driven by 1–4 residential real estate, farm loans, and CRE loans. 

  • Net charge-off ratio increased 3 basis points from the prior quarter to 0.19%, rising above the pre-pandemic average of 0.15%. 

  • Reserve coverage ratio continued to decline to 163.4%, indicating that allowance growth lagged increases in noncurrent loan balances.

Capital and Structural Stability

  • Capital ratios improved modestly across the board: CBLR rose to 14.10%, and the leverage capital ratio increased to 11%. 

  • Unrealized losses on securities fell by $1.7 billion (3.8%) from the prior quarter to $41.3 billion total. 

  • Community bank count declined by 38 during the quarter due to mergers, transitions, and one failure. 

Conclusion and Outlook 

The second quarter of 2025 showed continued momentum for community banks with higher net interest income increasing net income throughout the industry. Further, net interest margin increased 32 basis points from the previous year. However, challenges persist for the industry as non-interest and provision expenses increased during the quarter. Even with past-due and nonaccrual loans on the decline, net charge-off ratios increased slightly as well. With worsening economic conditions, financial institutions are starting to feel the pressure, and there is the expectation that ACL levels will increase. This is starting to be seen in ACL levels, as noted above, with provision expense increasing nearly 48% year over year. Although the magnitude of the increase and the need for an increase in reserve levels altogether can be significantly impacted by institution-specific circumstances, there is an expectation that these increases will continue for the time being. 

As we march through the second half of 2025, community banks should remain attentive to a shifting regulatory environment, particularly on the impacts of tariffs and the One Big Beautiful Bill Act (OBBBA) and how these changes will affect borrowers. The FDIC also proposed raising several key regulatory thresholds, including those that determine which institutions must comply with Part 363’s audit and internal control requirements. In this article, we provide additional information on the FDIC’s proposal. Furthermore, the United States took a historic step in digital finance on July 18, 2025, when President Donald Trump signed the Guiding and Establishing National Innovation for US Stablecoins (GENIUS) Act into law. This legislation introduces the first comprehensive federal framework for payment stablecoins and could potentially have significant implications on the banking industry. In this article, we take a deeper dive into the GENIUS Act and its potential impacts on community banks.  

So, to say there are a lot of moving pieces currently would be an understatement. BerryDunn has a Federal Impacts page, where we are frequently posting updates on the federal landscape. Check out this page for timely information that may impact your institution or your institution’s borrowers. 

Article
FDIC Issues its Second Quarter 2025 Quarterly Banking Profile

This article is for hospital CFOs, directors of reimbursement, and reimbursement managers. 

When it comes to Medicare reimbursement, the hospital Area Wage Index (AWI) may be one of the most important and often overlooked factors influencing your bottom line. This complex formula adjusts prospective payment rates based on regional labor costs and is calculated using data you submit, meaning small reporting decisions can lead to major financial impacts. Hospitals that fully understand how the AWI works and take a proactive approach to managing their data can optimize their Medicare revenue and strengthen long-term financial stability. This article breaks down how the wage index is calculated and offers practical strategies to help you avoid common pitfalls, support audit readiness, and take full advantage of this critical reimbursement mechanism. 

What is the hospital AWI and how is it calculated? 

Developed by the Centers for Medicare & Medicaid Services (CMS), the hospital AWI is used to adjust Medicare payments to short-term, acute care hospitals under the Prospective Payment System (PPS) to account for geographic differences in hospital labor costs. It compares the average hourly wages of PPS hospitals in a specific labor market area to the national average. Essentially, the AWI enables hospitals in higher-wage areas to receive more reimbursement to reflect their higher costs, while those in lower-wage areas receive less.  

Updated annually, the AWI is calculated for each specific labor market area defined by Core-Based Statistical Areas (CBSA) as established by the US Office of Management and Budget (OMB). To calculate the AWI, CMS determines the average hourly wage from aggregated hospital data for each CBSA and compares it to the national average. For example, if a CBSA has an average hourly wage of $50 and the national average is $40, the AWI would be 1.25. This factor is applied to the labor-related portion of Medicare’s hospital payment rates to ensure more equitable reimbursement across regions with varying labor costs.   

The wage index is derived from data reported by all PPS hospitals located within each CBSA, including data from annual Medicare cost reports and occupational mix surveys completed every three years. The hospital-reported data is audited, including review of payroll records, contracts, invoices for contracted labor, and other wage documentation to validate amounts reported. As such, there is a four-year delay from the reporting of wage data in cost reports to the Federal Fiscal Year (FFY) that the wage data is used to calculate the AWI. For example, the Medicare hospital AWI used to establish prospective payments for the FFY 2026 is based on hospital data from fiscal years beginning during the FFY 2022.  

The following chart, which includes data from the Centers for Medicare & Medicaid Services Fiscal Year 2025 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule, illustrates the significant impact that the wage index factor has on hospital reimbursement. 

Strategic considerations for hospitals 


Accuracy of submitted data 
CMS scrutinizes wage index data with a high level of detail. Inaccurate or inconsistent reporting can result in reimbursement reductions or even penalties. Errors may stem from incorrect wage classifications, exclusion of eligible labor costs, or misalignment between cost report data and payroll records. Hospitals must ensure that their Medicare cost report and occupational mix survey submissions are complete, clearly documented, and compliant with CMS guidance. Regular internal reviews and cross-checks between finance and HR departments can reduce the risk of discrepancies and support a smoother audit process. 

Strategy tip: Establish a wage index review team with finance, reimbursement, and HR representation to ensure consistency and defensibility across all submissions. 

Occupational mix factor 
The occupational mix survey is required every three years and has a multiyear impact on the wage index. It adjusts for differences in staffing models among hospitals, particularly the proportion of higher-paid professionals like RNs compared to lower-paid roles such as LNAs. Even if your total wages remain constant, a change in your occupational mix can significantly alter your wage index and, by extension, your reimbursement. 

Strategy tip: If you've recently undergone staffing changes, make sure these are accurately reflected and that you’ve retained the documentation to support the reported mix.  

Contract labor reporting 
The rise in contract and traveler staffing has introduced new complexity to wage index reporting. CMS requires hospitals to include contract labor costs that are for direct patient care services, but only when wages and hours are clearly documented and the reported costs are only related to labor (not overhead, travel, etc.). Missing or incomplete contractor data can lead to an underreported wage index, which may reduce reimbursement. Many hospitals unintentionally leave out valid contract labor costs because of poor tracking or vendor relationships that don’t provide sufficient detail. 

Strategy tip: Work with your contracted staffing vendors to ensure all contracts and invoices separate wage related rates and hours from non-wage-related cost (travel, housing, administrative fees, etc.). Develop internal controls to flag and track qualifying contract labor throughout the year, not just at cost reporting time. 

Appeal and correction opportunities 
Each year, CMS publishes a preliminary wage index in the Inpatient Prospective Payment System (IPPS) rulemaking process, followed by a correction and appeals window. Hospitals have a narrow opportunity to review, identify errors, and file appeals or correction requests, but many miss this window due to resource constraints or lack of awareness. These opportunities can help recover significant underpayments if discrepancies are discovered. 

Strategy tip: Mark your calendar for the CMS wage index correction deadlines (typically late summer or early fall) and assign someone to monitor the release of proposed rules. Establish a process for reviewing CMS-calculated wage index factors against your internal expectations to quickly identify inconsistencies. 

Geographic reclassification opportunities 
If your hospital is in a lower-wage CBSA but competes in a higher-wage labor market (or is on the border of one), you may be eligible to apply for a wage index reclassification through the Medicare Geographic Classification Review Board (MGCRB). This allows hospitals to be reclassified into a nearby CBSA with higher average wages, potentially increasing your Medicare reimbursement. 

The application must demonstrate that the hospital meets specific criteria related to proximity, commuting patterns, and wage comparability. While the process is data-intensive and must be initiated well in advance (typically by September 1 for the following federal fiscal year), a successful reclassification can yield substantial reimbursement gains. 

Strategy tip: Evaluate your geographic and wage positioning annually. Even if you haven't qualified in the past, changes in market conditions or CMS rules may make you newly eligible. BerryDunn can assist with a feasibility analysis and guide you through the MGCRB application process. 

We’re here to help 

The hospital wage index is complex and reporting wage data is more than a compliance requirement; it’s a strategic lever that can influence millions in Medicare reimbursement. At BerryDunn, our reimbursement specialists can help you: 

  • Validate and optimize your wage index data submissions 
  • Prepare for audits, respond to inquiries, and assist with disputes 
  • Complete the occupational mix survey accurately and efficiently 
  • Analyze trends and opportunities in your wage index factors 
  • Identify opportunities for reclassification  
  • Monitor CMS rule changes that impact your hospital’s reimbursement 

To learn more about how we can help your hospital make the most of the wage index, please contact our reimbursement consulting services team.  

Article
Understanding hospital AWI's impact on Medicare reimbursement

In an era defined by rapid technological advancement and constant innovation, one truth remains unchanged: the success of any organization depends on its people. Employee engagement is not a nice-to-have—it’s a strategic imperative. BerryDunn’s Valuable Organizational Insights on Culture and Engagement (VOICE) assessment provides leaders with a research-backed, actionable framework for understanding and improving engagement. Unlike traditional surveys, VOICE translates insights into impact quickly, equipping organizations with tailored recommendations and tools that drive meaningful change within weeks.

What sets the VOICE apart from similar assessments is its ability to quickly move clients from insight to impact. The depth and practicality of the VOICE’s insights are designed to be immediately useful, enabling BerryDunn teams to offer tailored recommendations and tools that drive real change just a few weeks after the survey closes. The results are also presented in a way that empowers individual leaders to identify their own opportunities and take meaningful steps to strengthen engagement within their teams.

Understanding employee engagement

Decades of research have established employee engagement as a robust predictor of both personal and organizational outcomes. Engaged employees tend to exhibit higher job performance, greater well-being, and lower turnover rates (Neuber, Englitz, Schulte, Forthmann, & Holling, 2022; Saks, 2019). A recent study highlighted that engagement has a stronger effect on these outcomes in the public sector compared to the private sector (Borst, Kruyen, Lako, & de Vries, 2019).

BerryDunn defines engaged employees as those who feel a deep connection to their organization, consistently strive to contribute to its success, and are willing to go beyond their regular job responsibilities to achieve excellence. The VOICE assessment measures three critical dimensions of engagement: organizational commitment, emotional engagement, and behavioral engagement. For instance, statements like "I would recommend this organization to others as a good place to work" gauge organizational commitment, "I feel inspired to do my best work every day" assesses emotional engagement, and behavioral engagement is captured through items like "I go above and beyond what is expected of me every day." This conceptualization provides leaders with a holistic understanding of how employees connect with their work and their organization.

Organizational and work factors influencing engagement

The VOICE assessment includes 35 items that evaluate various organizational and work-related factors that influence employee engagement. These items are designed to be:

  • Actionable. Leaders should be able to think of actions they can take to improve their employees’ scores on every item without expert advice.
  • Reliable and accurate. All items are easy for respondents to rate consistently.
  • Comprehensive. The items reflect a broad range of factors that have been found to influence engagement in empirical peer-reviewed research.
  • Aligned with BerryDunn’s Organization Development (OD) services. BerryDunn consultants have recommendations and interventions that are proven to help you improve your employees’ engagement.

Identifying the key drivers of engagement

While many organizations focus on addressing the lowest-scoring survey items, BerryDunn's approach identifies the "key drivers" of employee engagement. These are the organizational and work factors that have the lowest scores and are most strongly correlated with overall engagement levels. By creating a composite score that includes both the strength of the correlation with engagement and the average score of each item, BerryDunn pinpoints the top key drivers. This method ensures that the recommendations BerryDunn makes based on the assessment results are both impactful and actionable.

In addition to quantitative analysis, the VOICE assessment gathers qualitative feedback through open-ended questions. This qualitative data provides essential context, which often reveals the underlying reasons for the numerical scores and offers deeper insights into employee experiences and perceptions.

Standard survey process and deliverables

BerryDunn will work with you to develop a timeline that meets your needs for the following four steps in the VOICE assessment process. With no modifications to the VOICE assessment, our consultants can deliver your VOICE report in less than a month from survey administration.

Initial consultation

BerryDunn will work closely with you to help you and your team gain a thorough understanding of the survey process and establish a timeline for survey administration and reporting. The assessment can be tailored to meet your specific needs by adding items that align with your other strategic objectives.

Survey administration

BerryDunn supports the survey distribution and response collection process, using proven techniques to achieve high response rates. A carefully planned timeline ensures maximum participation from employees.

Data analysis and interpretation

Using advanced statistical methods, BerryDunn identifies the key drivers of engagement by integrating both correlation strength and item scores to create a composite score. Open-ended responses are analyzed to add depth and context, providing a richer understanding of the quantitative data.

Reporting and action planning

The VOICE report includes a detailed analysis of key drivers and themes, as well as immediate actions that your leaders can take to improve their employees’ engagement. We also include tailored recommendations for employees at all levels to enhance their own engagement. This unique approach ensures that you gain immediate value, setting BerryDunn apart from others who often focus on selling additional services rather than delivering actionable insights from the outset. For those seeking further support, we offer an action planning workshop to collaboratively develop strategies that align with your organization’s goals.

Start your organization’s engagement journey

Improving engagement starts with understanding what matters most to your employees. The VOICE assessment provides leaders with clear insights and practical steps to strengthen commitment, performance, and culture. With results that lead directly to action, the VOICE helps organizations identify priorities and create an environment where people can do their best work.

References

Borst, R. T., Kruyen, P. M., Lako, C. J., & de Vries, M. S. (2019). The Attitudinal, Behavioral, and Performance Outcomes of Work Engagement: A Comparative Meta-Analysis Across the Public, Semipublic, and Private Sector. Review of Public Personnel Administration, 40(4), 613-640.

Neuber, L., Englitz, C., Schulte, N., Forthmann, B., & Holling, H. (2022). How work engagement relates to performance and absenteeism: a meta-analysis. European Journal of Work and Organizational Psychology, 31(2), 292-315.

Saks, A. M. (2019). Antecedents and consequences of employee engagement revisited. Journal of Organizational Effectiveness: People and Performance, 6(1), 19-38.

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Driving organizational success through employee engagement

Read this article if your organization relies on HHS grants. Effective October 1, 2025, new federal rules will impact how you manage your budget.

The US Department of Health and Human Services (HHS) has revised its federal grant policy, introducing stricter oversight into budget adjustments. Effective October 1, 2025, the new rule lowers the allowable rebudgeting threshold from 25% to 10%. This change is expected to significantly reduce reallocation flexibility. It will also increase the administrative workload and compliance risks for health centers and other HHS grantees.  

Then vs. now: Budget reallocation rules 

The previous rule allowed health centers and other HHS grantees to transfer funds between budget categories (e.g., personnel, fringe benefits, travel, supplies, contract services) without requiring prior approval, provided the cumulative changes were within 25% of the total approved federal grant budget. The new HHS grants policy statement cuts the threshold for prior approval requirements for budget revisions to 10% of the total approved federal budget (including any cost shares). For example, if a grantee makes several smaller budget category reclassifications that cumulatively add up to more than 10%, prior approval will be required.  

To put this in perspective, prior to the change, a grantee with a $1 million grant could reallocate up to $250,000 per budget category without prior approval. Under the new policy, reallocation is limited to $100,000 per budget category. This reduction substantially restricts grantees’ flexibility in managing grant expenditures. 

Calculating the new threshold 

The 10% threshold is cumulative across all reallocations affecting a budget category, not calculated per individual reclassification. For example, for a $1 million grant, if a grantee reclassifies $75,000 from personnel to contract services and then reclassifies $50,000 from fringe benefits to contract services, the reclassifications of both personnel and fringe benefits are below the 10% threshold individually. However, the total impact on contract services exceeds the threshold and would require prior approval. 

The change only applies when the grant award exceeds the Simplified Acquisition Threshold (SAT), which will increase from $250,000 to $350,000 on October 1, 2025.  

Impacts for health centers and why this matters

For health centers, which are accustomed to ample flexibility in how they spend HHS grant funds, this change in policy will require diligence in monitoring grant expenditures and staying alert to changes that could trigger the need for prior approval from their grants manager for budget revision. 

The new rule adds to the administrative burden for health centers and other grantees already grappling with funding gaps. Budget shifts that exceed the lower 10% threshold cannot be implemented until prior approval is granted. Approval typically is not retroactive. As a result, centers are unable to redirect grant dollars in real time and must wait to cover essential expenses. 

The change will likely lead to an increase in prior approval requests, creating delays given limited federal staff capacity to review them. Smaller health centers are expected to feel the impact more acutely since their payroll is often heavily grant-funded, making them more likely to exceed the 10% reclassification threshold. With fewer resources, their finance teams face added pressure managing forecasting, reporting, and approval delays.  

Proactive, strategic planning is key. Grantees must get prior approval in advance of reclassifying items in their budget. Failing to do so increases audit and compliance risks, as auditors will focus on this due to the significance of the change.  

Immediate actions for health centers and other grantees 

The new rule requires health centers and other grantees to closely monitor grant expenditures and be aware of changes that could require prior approval on a budget revision. Health centers should take the following steps to ensure compliance with the new 10% threshold: 

  1. Conduct a thorough review of all budget reallocations made to date.  
  2. Identify any reallocations that exceed the new 10% threshold and did not receive prior approval.  
  3. Submit prior approval requests for any further reallocations as soon as possible.  
  4. Adjust internal processes to ensure future reallocations are tracked and approved in advance. 

Now is the time to assess the budget process and determine how to alter current processes to remain compliant. 

BerryDunn can help

With this tightening of federal oversight, health centers need to prepare by implementing proactive monitoring and strategic planning to ensure compliance and avoid administrative delays. By closely monitoring grant expenditures and securing prior approvals, health centers and other grantees can mitigate risks and continue to utilize their grant funds effectively. Now is the time to assess and adapt budget processes to align with the new requirements. 

BerryDunn’s team partners with a diverse range of healthcare organizations—including Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes (LALs), and Rural Health Clinics (RHCs)—to enhance efficiency, improve patient outcomes, and strengthen community health systems. In a rapidly evolving regulatory environment, our healthcare compliance consultants help community health centers navigate complex compliance requirements, from grant and 340B program adherence to healthcare credentialing. With expert guidance, we help you mitigate risk, gain regulatory confidence, and enhance operational integrity. Learn more about our services and team.  

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New HHS grant policy: Implications and actions for health centers and other grantees

In today's rapidly evolving business landscape, boards of directors are more than just stewards of governance—they are the strategic compass guiding an organization toward enduring success. As the challenges facing companies grow increasingly complex, from disruptive technological trends to shifting societal expectations, the board's role has never been more critical.  

This series is designed to empower board members with the insights and tools necessary to navigate change with confidence. Our experts, each a leader in their respective fields, will share real-world examples, practical frameworks, and actionable advice in a Q&A format, as well as lessons learned from their personal and professional journeys.   

Learning and development: Developing talent

For the latest installment of our board leadership series, BerryDunn Director of Learning & Development, Shawn Tuttle, shares key insights on developing talent within an organization, including the importance of experiential learning, artificial intelligence, employee retention, and the role of managers.  

Q: What professional experiences helped shape your perspective on Learning & Development?  

A: Early in my career, I participated in, and then led, experiential outdoor leadership programs. They were pivotal for me and my career. The experiential nature of them was incredibly impactful. As a result, I recognize the tremendous value of experiential learning such as real-world practice and application, coaching, mentoring, feedback, and communities of practice. Over the past three years, the entire BerryDunn Learning & Development team has worked to provide frameworks and systems to advance and embed these types of learning experiences at the firm. 

Q: What impact has the development of BerryDunn’s strengths-based culture had? 

A: It has been rewarding to foster and witness the firm’s growing strengths culture from the expansion of the suite of courses and requests for custom sessions, to meaningful personal examples and testimonials. CliftonStrengths is an empowering resource and tool through which we can all learn to be at our best—more collaborative and more effective, both personally and professionally. The more we use our unique talents, the more energizing our work is.  

Q: What trends or challenges do you see impacting the future of Learning & Development? 

A: Artificial intelligence is being used in myriad ways and is, once again, providing us with new ways to learn—especially in the moment and through role play—and new ways to create learning resources. The possibilities are exciting and there are more and more advanced tools for our industry being developed. While we’re not quite ready to move in that direction in a big way, we are looking in that direction and staying aware of all that is happening. 

Q: What do you consider the most critical skills for employees to develop in today’s work environment and how do you foster their growth? 

A: Some key capabilities necessary for the ways we work and the current environment include strong and efficient collaboration, adaptability and flexibility, compassion, and inclusivity. But I also always come back to self-leadership. When we maintain responsibility for our own behavior, initiative, development, and performance, we proactively bring our best to our roles.   

Q: How do you tailor development programs for remote or hybrid employees, and what additional challenges do you face in this context?   

A: All of our current offerings are virtual, eliminating any difference in experience based on work location. However, we frequently offer custom sessions with departments and practice groups that are hybrid and advise on the planning of hybrid events. What’s critical for the success of hybrid events is careful attention to planning the engagement of all participants, regardless of where they are located. 

While hybrid events are a reality of how we operate inclusively, careful attention to maintaining inclusivity during the events is challenging and important. A must-have for us is engaging both an in-person and an online facilitator for hybrid events. 

Q: What role does employee development play in improving employee retention, and how do you make sure that development programs have a lasting impact? 

A: Growth and development are key aspects of employee engagement. This is why the firm measures it through the annual employee engagement survey. As a firm that values and invests in its people, BerryDunn excels in this area, offering opportunities to learn new skills and capabilities, grow professionally, and advance careers. When an employee has someone at work who encourages their development, as well as opportunities to learn and grow, they are more likely to stay with their organization.   

Q: What role do managers and team leaders play in supporting employee development, and how do you train them to be effective in this role? 

A: People managers impact 70% of team engagement according to Gallup research, which, as noted above, is heavily influenced by the opportunity employees have to develop. Our leadership competencies set clear expectations, and our self-directed leadership journeys provide a roadmap for managers and leaders to develop these capabilities. One of our competencies in particular outlines the importance of the need for managers to help employees belong, grow, and thrive by cultivating an environment of trust, curiosity, and openness.  

The leadership development journeys offer resources for engaging in learning activities, practical experiences, reflection questions, and guidance on seeking feedback. We also have a strong mentor program, which provides an opportunity to partner with a mentor for direct guidance and support. Lastly, we are in the process of planning for developing our leaders as coaches, providing coaching options, and considering cohort structures to support learning in community.

About Shawn 

Shawn Wade Tuttle is a strategic leader with a track record of improving organizational performance through learning, development, and process improvement. With broad experience in education across K12, higher education, nonprofit, and corporate sectors, she combines curiosity, clarity, and collaboration with practical strategy that leads to sustainable solutions. As Director of Learning & Development at BerryDunn, Shawn fosters a culture of continuous development, supports long-term capability building, and helps enhance employee engagement. She is known for designing scalable systems that align with strategic goals, building high-performing teams, and developing strengths-based organizations. Before BerryDunn, Shawn held leadership roles at Tufts University, City Year, and Harvard University, where she strengthened client engagement, enhanced cross-functional collaboration, and expanded professional development initiatives. She holds dual BAs from UMass Amherst and is certified as a Gallup® CliftonStrengths Coach and Prosci® Change Management Practitioner. 

BerryDunn partners with organizations to create work environments where business success and personal growth coexist and where people are confident knowing their workplace positively contributes to their well-being. We take a comprehensive approach to our workforce and well-being work, considering how business needs, organizational capacity, and the employee experience work together to drive your business forward. Learn more about our workforce and well-being team and services.   

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