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For many hospitals and health systems implementing Electronic Health Record (EHR) systems, the "go-live" milestone is less of a celebration and more of a stumbling point—even when the implementation seemed like a triumph. Why does this happen? The truth is, go-live is just one of many milestones on the long ascent of your EHR journey.

The real aim of a large-scale EHR project isn’t simply to reach the summit and plant your flag. The goal is to operate the EHR effectively in daily life: gaining efficiencies, making clinical improvements, enhancing patient experience, and restoring or surpassing your previous financial benchmarks.

Climbing the EHR mountain 

Think of your EHR investment like climbing a formidable mountain. No climber sets out just to stand at the summit indefinitely. The true adventure is reaching the top and then making it safely back down—stronger, wiser, and with stories to tell. EHR go-live is that moment at the peak. The journey, however, is far from over.

Many organizations invest in an EHR and create plans that focus only on reaching the summit, neglecting the path home. This oversight leads to exhausted staff, inadequate post-go-live support, declining morale, finger-pointing, and a dangerous slide back into old habits—negating the entire reason for the climb.

Let's explore the unique perils that await after go-live, as hospitals trek from the summit back to normal operations. While there are hazards along the way, these strategies will help you stay on course and avoid danger.

Peril 1: Fatigue at the summit

Just as climbers expend their greatest energy reaching the top, so too do teams give their all in the final days before go-live—last tests, make-or-break decisions, intensive user training, and two weeks of command center operations. When the summit is reached, people are tired. They want to pause and catch their breath, leaving them vulnerable to mistakes.

Strategy: Guard against fatigue

• Set daily work-hour limits during command center operations and monitor total hours closely.
• Allow time for team members to recharge; consider rotating schedules so not everyone is off at once.
• Designate post-go-live reinforcements to relieve the primary climbers once the summit is reached.

Peril 2: Letting your guard down

It’s easy to feel safe once you’ve reached the summit. The command center closes, the vendor departs, and talk turns to optimization visits and transitioning to vendor support. But the path down the mountain—those crucial 6 to 12 months after go-live—can be treacherous.

Strategy: Stay vigilant on the descent

• Maintain a daily post-go-live huddle, even when the formal command center disbands. This continued cadence keeps eyes on the trail.
• Remind your team: the journey isn’t finished, and dangers still lurk.
• Resist vendor pressure to transition to support until your team truly feels ready – use your baseline KPIs to help determine when you are ready.

Peril 3: Running low on provisions

On a mountain, running out of food or water during the descent can be dire. In EHR projects, organizations can burn through financial reserves more quickly than expected—especially with extra testing, third-party support, or extended clinical coverage. After go-live, cash inflow can slow, leaving the organization scrambling for resources.

Strategy: Keep supplies in reserve

• Utilize both contingency funds (for known risks) and management reserves (for unknowns) throughout implementation and post–go-live.
• Monitor key financial indicators like days cash on hand and line of credit usage.
• Plan for the dual challenge of winding down the legacy AR while managing the new AR, allocating sufficient resources for both worlds.

Peril 4: Coming down too fast

Gravity aids your descent, but it also brings new dangers—slipping, speeding, and tumbling down the slope. In EHR go-lives, the “gravity” is the momentum of rapidly accumulating, unchecked transactions. A simple misstep—a missed billing or coding queue due to training gaps or configuration errors—can snowball into a labor-intensive recovery.

Strategy: Manage EHR gravity

• Identify and address transaction “snowballs” quickly. Know which reports to run and how to spot growing backlogs.
• Focus on fixing root causes, not just symptoms, to prevent further accumulation.
• Ensure your team is properly trained on critical workflows and have super users ready to provide targeted remediation.

Peril 5: Getting lost on the trail

Fatigue, a sense of accomplishment, and the illusion of safety can cause teams to lose track of their route. In the EHR world, this can mean ballooning AR, mounting DNFB, accumulating referrals, increasing provider pajama time, and lengthening patient wait times—often unnoticed until you’re deep in the woods.

Strategy: Stay on course with clarity 

• Chart your descent with clear KPIs for success and monitor them religiously.
• Seek outside perspectives—consult with your team, bring in experts, and never hike alone.
• Regularly stop to check your bearings using dashboards and visual indicators to ensure you’re on the right path.

Peril 6: Chasing perfection

Every climber dreams of the perfect ascent and descent—ideal routes, well-timed rests, and a flawless return. But rigidly sticking to a plan, especially when conditions change, can lead to greater risk. In EHR projects, this is most evident in the revenue cycle, where teams may become fixated on perfect claims and charges, ultimately slowing cashflow and putting the organization in jeopardy.

Strategy: Focus on progress, not perfection

• Emphasize continuous improvement rather than perfection. Revenue cycle performance doesn’t have to suffer after go-live—deficiencies can be addressed with proper planning, testing, and training.
• Avoid holding claims for unneeded double (or even triple) checks before submission; this creates unmanageable queues and delays.
• Focus on building robust edits and workflows that prevent defects, acknowledging that denials and rejections will occur, but can be minimized over time.

Thriving beyond EHR go-live

Being aware of the perils and the strategies to address them can help your team thrive through go-live and beyond. The true measure of success is not reaching the peak, but returning stronger—delivering thriving operations, satisfied patients, and healthy financial performance with your new EHR system.

The mountain is waiting. Plan your entire journey, and you’ll return home triumphant.

Fulfilling the promise of healthcare technology

BerryDunn has an objective and experienced team dedicated to healthcare IT, including clinicians, IT experts, and former department heads who have hands-on experience in implementing EHR, ERP, and other health IT systems successfully. Whether you need guidance through the entire process or have specific needs, we customize our services based on where you are today. Learn more about our team and services. 

The Public Company Accounting Oversight Board (PCAOB) has released its 2024 Annual Report on the Interim Inspection Program for audits of broker-dealers. This 10th annual report outlines persistent deficiencies in broker-dealer audits and attestation engagements. For management and audit committees, the report offers crucial insights into audit risks, regulatory expectations, and areas where stronger oversight is needed.

Persistent deficiencies raise oversight red flags

In 2024, the PCAOB inspected 60 accounting firms and reviewed 102 audits of broker-dealer financial statements. The PCAOB also examined 93 related attestation engagements—either examinations of compliance reports or reviews of exemption reports. The results were:

• 66% of broker-dealer audits had at least one deficiency related to audit evidence.
• 59% of compliance examinations and 42% of exemption reviews were found deficient.
• Deficiencies were most prevalent among smaller firms that audit fewer broker-dealers or issuers.

These statistics reflect a growing concern about audit quality in the broker-dealer space—and highlight where management and audit committees should be particularly vigilant.

Key areas of concern identified
 

1. Revenue recognition and accuracy

Deficiencies in auditing revenue were the most common and serious. This is nothing new, as revenue had been the area cited with the most deficiencies in the 2023 and 2022 reports as well. Of the 102 audits reviewed, 97 included revenue testing—nearly half (48%) had deficiencies.

Common problems included failure to:

• Verify the accuracy of commissions, advisory fees, 12b-1 fees, and merger/acquisition fees.
• Confirm that performance obligations were distinct and satisfied prior to revenue recognition (as required by ASC 606).
• Disaggregate revenue sources appropriately to reflect their nature and timing.
• Assess the classification and disclosure of revenue, including required qualitative information.
• Test the accuracy and completeness of third-party reports (e.g., clearing broker data) used in audit procedures.

For example, some firms did not test whether securities trade amounts and commission rates were accurate, nor did they evaluate whether revenue from variable annuity trails or 12b-1 fees should have been disaggregated. Others did not ensure advisory fee calculations were tied to accurate Assets Under Management (AUM) data or fee schedules.

Takeaway for management and audit committees:

Audit committees should confirm that revenue processes—including fee calculation, classification, and third-party data use—are well-documented and transparent. Management should ensure contracts and performance obligations are clearly delineated and that disclosures meet ASC 606 requirements. An ASC 606 practice aid, which walks management through the five-step revenue recognition process, can be useful to take inventory of the broker-dealer’s various contracts and how revenue from those contracts should be recognized in the financial statements. Such a practice aid can also prove useful in crafting ASC 606 disclosures.

2. Journal entry testing and fraud risk

Deficiencies in journal entry testing—critical for identifying and responding to fraud risk—were found in 18% of audits.

Common issues included:

• Failing to test the completeness of journal entry populations
• Selecting entries without considering fraud risk characteristics
• Reviewing listings but not examining supporting documentation
• Excluding flagged entries from testing without documented rationale
• Testing too few entries to provide sufficient audit assurance

The PCAOB specifically noted that many auditors failed to respond appropriately to the risk of management override of controls—a key component of fraud risk under PCAOB standards.

Takeaway for management and audit committees:

Ensure your auditors are applying rigorous, risk-based journal entry testing and that internal finance and compliance teams are involved in identifying and monitoring manual entries, especially at period end. Make sure that supporting documentation is retained for all posted journal entries. Also, ensure the journal entry posting process is clearly documented, including the types of journal entries that can be posted, by whom, and who the designated reviewer is. Having such a process clearly documented will make it easier for auditors to understand your broker-dealer’s journal entry process, which is a critical first step in effective journal entry testing.

3. Related party relationships and transactions

Deficiencies in this area were particularly concerning given the potential for misstatement or hidden liabilities. The PCAOB found that some auditors:

• Did not test allocations of revenues and expenses between broker-dealers and affiliates
• Failed to assess the financial capability of affiliates to cover material receivables
• Missed required disclosures of related party transactions under ASC 850

In one case, auditors accepted related-party expense allocations without verifying whether they were accurate, complete, or consistent with underlying agreements.

Takeaway for management and audit committees:

Ensure formal agreements with affiliates are in place and that intercompany transactions are reviewed regularly. If changes to related party transactions are made, these changes should be formally documented in the form of agreement amendments. If an allocation methodology, such as headcount or time studies, is used, broker-dealers must ensure this allocation methodology is thoroughly documented and followed. Disclosures about related parties must be clear and complete. Committees should confirm that auditors are probing related party risks—not just accepting management’s assertions.

Key areas of concern identified – examination engagements (compliance reports)

Of the 29 examination engagements reviewed, 59% had at least one deficiency. Common issues included:

• Incomplete testing of controls over compliance with SEC financial responsibility rules (e.g., the Net Capital Rule, Customer Protection Rule)
• Failure to evaluate the design and operation of controls with a review component (e.g., how management reviews reserve computations or account statements)
• Insufficient testing of IT general controls upon which other control procedures depended
• Lack of compliance testing over reserve account balances and the existence of securities held for customers
• Improper or missing representation letters from broker-dealer management
• Failure to issue modified opinions when material weaknesses in internal control over compliance (ICOC) existed

Takeaway for management and audit committees:

Engage in proactive conversations with your auditor about the internal controls they expect to see in place over the financial responsibility rules. Gain an understanding of your auditor’s testing approach, ensuring it aligns with the expectations of the PCAOB. Throughout the year, make sure sufficient documentation is retained so your auditor can easily test ICOC. Again, what is deemed sufficient should be determined through proactive conversations with your auditor.

Key areas of concern identified – review engagements (exemption reports)

Among the 64 review engagements evaluated, 42% had deficiencies. Key failures included:

• Inadequate understanding of the broker-dealer's exemption under Rule 15c3-3
• Insufficient inquiry into controls or monitoring practices related to exemption compliance
• Failure to test or inquire about the handling of customer checks to ensure prompt transmittal
• Errors or omissions in review reports—such as referencing assertions not made or failing to include required language

Takeaway for management and audit committees:

If your broker-dealer claims an exemption, ensure operational practices support that status. Review internal monitoring processes and make sure what is happening in practice aligns with your written supervisory procedures. If exceptions to your exemption status are identified, ensure they are promptly corrected and that your auditor is notified of the exception.

What you can do now

To help improve the quality of oversight:

• Engage in proactive dialogue with your auditor about the PCAOB’s findings and how they apply to your engagement.
• Assess your auditor’s broker-dealer experience—particularly if your firm is served by a smaller firm.
• Re-examine and test your internal controls over customer protection, capital computations, revenue recognition, and related-party arrangements.
• Strengthen audit committee oversight by requesting clear audit strategies, better documentation, and enhanced reporting on high-risk areas like revenue and related parties.
• Confirm that required auditor communications are received and appropriately documented.

Final thought

The PCAOB’s report is a call to action—not just for auditors, but for management and those charged with governance. As regulatory expectations continue to rise, management and audit committees must ensure that internal processes, control environments, and auditor relationships are all aligned to support accurate, transparent, and compliant financial reporting.

About BerryDunn

BerryDunn's financial services team understands the complex regulatory environment that broker-dealers operate in and provides practical solutions to help you stay ahead of requirements. From broker-dealer financial statement audits to tax preparation and compliance to consulting services, we tailor our services to meet your unique needs. Learn more about our team and services.

The Centers for Medicare & Medicaid Services (CMS) issued the final rule for the PPS for SNFs for FY 2026 which was published in the Federal Register on August 4, 2025; the regulations in this rule are effective October 1, 2025.  

The rule: 

• Updates the PPS payment rates for SNFs for FY 2026 using the market basket update and budget neutrality factors effective October 1, 2025. 

• Updates the International Classification of Diseases, 10th Revision, Clinical Modification (ICF-10) code mappings used under PDPM. 

• Updates the SNF Quality Reporting Program (SNF QRP).

• Updates the SNF Value-Based Purchasing (SNF VBP) Program. 

2026 PPS rate calculations 

The final rule provides a productivity-adjusted market basket increase for SNFs of 3.2% beginning October 1, 2025, which reflects: 

• A market basket increase of 3.3% based on IHS Global Inc.’s (IGI’s) second quarter 2025 forecast with historical data through the first quarter of 2025.  

• An upward forecast error adjustment of 0.6% due to the difference between the estimated and actual percentage increase in the market basket exceeding the 0.5 percentage point threshold.  

• A downward 0.7 percentage point multifactor productivity adjustment (based on the 10-year period ending September 30, 2026).  

The unadjusted federal rates for FY 2026, prior to adjustment for case-mix, are as follows: 

FY 2026 Unadjusted Federal Rate Per Diem – Urban 

FY 2026 Unadjusted Federal Rate Per Diem – Rural 

The rates shown in the tables above are subsequently case-mix adjusted, and a facility-specific wage index—determined by the Core-Based Statistical Area (CBSA) in which each facility is located—is also applied. To assist you with the calculation of your facility-specific PPS rates for FY 2026, our experts at BerryDunn have updated our interactive rate calculator, which is part of the BerryDunn Senior Living Portal.  

Please note: The rates per our calculator are prior to any FY 2026 VBP adjustment. When CMS releases the final VBP incentive payment multipliers for FY 2026, BerryDunn will update the interactive rate calculator as necessary. 

CMS estimates that the aggregate impact of the payment policies in this final rule would result in a net increase of 3.2%, or approximately $1.16 billion, in Medicare Part A payments to SNFs in FY 2026. This estimate does not reflect a projected $208.36 million decrease as a result of the SNF VBP program reductions. 

The projected overall impact to providers in urban and rural areas is an average increase of 3.1% and 3.7%, respectively, with a low of 2.0% for urban Pacific providers and a high of 6.6% for rural Mountain providers—actual impact will vary. 

Changes in PDPM ICD-10 code mappings 

CMS has changed the clinical category assignment for 34 new ICD-10 code mappings that were effective October 1, 2024. These updated code mappings can be found on the PDPM website. 

SNF QRP Update 

Updates to the SNF QRP Program include: 

• CMS finalized removing four items that were previously adopted as standardized patient assessment data elements in the Social Determinants Of Health (SDOH) category, starting with the FY 2027 SNF QRP. These are: 

  • One item related to Living Situation,

  • Two items concerning Food

  • One item regarding Utilities   

• Finalized and codified changes to the reconsideration policy and process. Now, SNFs will be permitted to request an extension to file a reconsideration request. Additionally, CMS is updating the criteria that will be used to evaluate and potentially grant these reconsideration requests. 

SNF VBP Program update 

Updates to the SNF VBP Program include: 

• The Health Equity Adjustment (HEA) will be removed beginning in the FY 2027 program year, to streamline the scoring methodology and offer clearer incentives for SNFs.  

• Final performance standards for the FY 2028 and FY 2029 program years were provided to meet the SNF VBP Program's statutory notice deadline.  

• The previously established scoring methodology will be applied to the SNF Within-Stay Potentially Preventive Readmission (SNF WS PPR) measure, starting with the FY 2028 program year, to align the scoring methodology for this measure with the scoring methodology previously finalized and applied to all other measures in the measure set.  

• Adoption of a new reconsideration process, allowing SNFs to seek reconsideration on Review and Correction requests. 

The following table lists the measures that have been adopted for the SNF VBP Program, along with their status in the program for the FY 2026 program year through the FY 2029 program year. 

If you have any specific questions about the final rule or how it might impact your facility, please contact Ashley Tkowski or Melissa Baez. 

As financial institutions continue to navigate evolving regulatory landscapes, the recently enacted OBBBA legislation introduces a noteworthy incentive aimed at supporting rural and agricultural development. Effective July 4, 2025, the bill provides a 25% federal income tax exemption on interest income earned from qualifying rural or agricultural real estate loans.  

This represents a strategic opportunity for lenders to reassess their portfolios and tax planning strategies. With further guidance expected, institutions should begin preparing to identify eligible loans and evaluate the broader implications of this new provision. 

Key information for financial institutions 

• Effective date: Applies to qualifying loans originated on or after July 4, 2025. 
• Exemption: 25% of the interest income earned on these loans will be tax-exempt. 
• Ineligible loans: Refinanced loans do not qualify. 
• Qualified loans: Loans must be secured by rural or agricultural real estate, defined as property substantially used for: 

• Producing agricultural products (not defined) 
• Fishing or seafood processing 
• Aquaculture (hatcheries, rearing ponds, pens, etc.) 
• Leasehold mortgages on such real estate also qualify, provided they have lien status 

Please also note that, similar to municipal bond investments, these loans are subject to IRC Section 265, which may limit deductibility of interest expense allocable to the tax-exempt income. 

Considerations for financial institutions

Loan identification and tracking: Determine whether any existing lending activity aligns with these definitions and develop a method for flagging and tracking qualifying loans after the effective date. 

Strategic expansion: Assess whether this creates an incentive to expand your presence in agricultural or rural real estate lending. 

Loan pricing models: Revisit pricing for these types of loans to account for the blended tax benefit and any associated disallowed interest expense. 

Tax planning: Analyze how this partial exemption could affect your effective tax rate and broader tax strategies going forward, particularly as it creates a permanent tax difference. 

About BerryDunn

BerryDunn's dedicated audit, tax, and consulting professionals understand the financial services industry and its challenges and are committed to helping you meet and exceed regulatory requirements. We partner with you to bring tailored approaches to fit your needs and operations and provide guidance on best practices and recommendations that make sense for you. Learn more about our services and team.  

Executive Order (EO) 14221 released on February 25, 2025, directed the Secretaries of Labor, Health and Human Services (HHS), and the Treasury to implement changes to improve implementation and increase enforcement of the hospital price transparency (HPT) rule. On May 22, 2025, the agencies announced progress in implementing the EO, including issuance of a request for information (RFI), as well as providing updated guidance regarding requirements for machine readable files. 

HPT enforcement 

An HHS Office of Inspector General (OIG) audit report released in November 2024 estimated only 46% of hospitals were in compliance with HPT rule requirements. While the HHS OIG noted a variety of issues with shoppable services requirements, the most common areas of non-compliance observed related to the machine readable file (MRF), including: 

• Failing to update the file annually 

• Lack of appropriate naming conventions 

• Providing negotiated charges by payer/plan

Civil monetary penalties (CMP) for HPT non-compliance range from $300 to $5,500 per day, depending on hospital bed count. From 2021 – 2024, CMS issued CMP notices totaling approximately $5 million.  

Based on reports from our clients and anecdotes shared by compliance and finance colleagues and from presenters at recent conferences, HPT-related complaints from patients have remained minimal, whereas the pace of CMS non-compliance warning letters has increased. 

Practical tips for HPT compliance 

The risks related to non-compliance with HPT rules can be mitigated through a multidisciplinary team approach, establishing accountability, and engaging external resources to fill gaps in expertise. 

• Making certain to include the functions with an HPT role, such as finance, revenue cycle, revenue integrity, compliance, IT, and payer contracting 

• Considering the vendor as part of the team if any aspect of HPT rule compliance is outsourced 

• Designating an internal resource to monitor and advise your team on HPT-related announcements from regulators and CMS enforcement activity 

• Linking chargemaster/CDM and fee schedule updates to MRF and shoppable services maintenance activities supports compliance with multiple HPT requirements 

• Adding HPT-related audit items to the compliance work plan to demonstrate internal oversight 

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.