The client and the question
The client is a multi-state ABA provider operating clinics in several states across the Midwest and South. In 2025 it served 492 clients with 384 BCBAs and RBTs and billed $12.81M of contract value, meaning the payer's agreed rate multiplied by authorized, delivered and documented units. It came to us for billing and payer enrollment support, and asked a direct question: why does a book that is almost entirely pre-authorized collect so much less than it should?
In ABA that question is sharper than in most specialties. If a service was authorized, delivered and documented, and the claim was clean, the payer should pay the contracted rate. Any persistent gap between contract value and cash is a process gap, not a pricing one.
What the numbers showed
We worked from the full billing history, not a sample: every claim line from 2022 through August 2026 and every remittance line in the payment ledger. Across that period the group billed $50.55M of contract value and collected $42.82M, or 84.7%, with $8.33M still open.
Net collection on contract value had fallen from 95.1% for 2022 services to 85.3% for 2025 services, while annual contract value grew from $8.06M to $12.81M. The 2022 figure proved the payer mix could support collection above 95%. The decline tracked growth: the front end scaled and the back end did not.
The contradiction that was the diagnosis
The first measurement of first-pass yield came back at 92.5%. That number could not be right alongside 84.7% collected, and the contradiction pointed straight at the cause. A claim line was being counted as clean because it carried no denial code, and a claim that has never been answered carries no denial code either.
Measured correctly, as contract value paid in full on the first remittance received, first-pass yield was 65.8%. Of billed contract value, 10.1% had never been answered at all and 8.6% was denied on first pass. Denials were real, but they were not the main story: 49.8% of denied dollars were eventually recovered. The silent claims were never worked because nothing told anyone they existed.
Where the open receivable actually sat
We split the $8.33M open receivable into three parts that add up without overlap.
| Component | Contract value | Share of open receivable | What it means |
|---|---|---|---|
| Never claimed | $402K | 4.8% | Mostly current work in progress on 2026 service dates |
| Claimed, never answered | $5.05M | 60.6% | No payment, no denial, no remittance line; $4.13M submitted over 60 days ago, $3.44M over one year |
| Answered and left open | $2.88M | 34.6% | Includes $1.76M denial-coded and $1.25M patient responsibility |
Remittance coverage separated enrollment from follow-up
For each payer we measured remittance coverage: the share of billed claim lines that ever produced a remittance line. One state Blue plan showed 4% coverage and 4% net collection, with $424K of claims sitting silent. That is not a follow-up problem. Claims were never being adjudicated, which is the signature of an enrollment failure.
Several Medicaid managed care plans sat between 65% and 78% coverage, which called for an enrollment and member-registration audit. The largest commercial payers were at or above 88%, where the remaining silent dollars were a claim-status discipline problem. The diagnostic told the client which work belonged to credentialing and which to billing.
What the front end got right
A diagnostic that only finds faults is not credible, and this one tested the clinical billing as hard as the back end. The results were strong.
- Units billed matched time worked on every one of 340,744 fifteen-minute-code lines; no line billed more units than the session lasted.
- Every claim line carried a linked authorization, 99.1% of lines fell inside the authorized date window, and 99.9% billed a code the authorization listed.
- Of 26,409 sessions never converted to claims, only $43,083 of billable value existed across four and a half years, 0.086% of contract value. We reported it as timing, not as lost revenue.
What we put in place
We work inside the client's own practice management system, under its existing payer enrollments, as users rather than as a new submitter. That decision meant no payer had to re-enroll anything, so the transition became a single date-of-service cutover across all states and payers instead of a payer-by-payer migration.
The operating changes followed the diagnosis, in this order.
- First, a claim-status loop at day 21, 35 and 45 for every claim with no remittance, worked through each payer's portal or electronic status channel.
- Alongside it, remittance coverage by payer every month, with enrollment and ERA defects routed to payer enrollment rather than to billing.
- Next, separate ERA and EFT enrollment for each group NPI at the clearinghouse, so remittances stop landing in the wrong system.
- Then, cash application and a bank-to-ledger reconciliation, so the true receivable is established before anything is written off.
- Every month thereafter, first-pass yield measured on contract value with unanswered claims counted as failures.
The opportunity, sized honestly
Patient responsibility sits inside contract value, so 100% collection is not reachable without collecting from families; copays billed were $1.74M and $486K was collected. The realistic all-in ceiling is about 95% to 97%. Moving net collection from 85.3% to 95% on the group's annual book is worth about $1.21M a year. That is a target the operating changes are built to reach, not a result we are reporting.
We also declined to count what could not be collected. Unused authorized units reflect therapy capacity, not a billing recovery, and session-conversion counts were reported in dollars so a large count did not overstate a small amount of money.
Frequently asked questions
What is net collection on contract value?
It is cash collected divided by contract value, where contract value is the payer's agreed rate multiplied by the units that were authorized, delivered and documented. In ABA it is a more honest measure than gross collection rate because almost every service is pre-authorized at a known rate, so any gap between contract value and cash points to a process problem rather than to pricing.
Why was first-pass yield first reported at 92.5%?
Because the first measurement treated any line without a denial code as clean. A claim that has never been answered also has no denial code, so silent claims were counted as successes. Measuring first-pass yield as contract value paid in full on the first remittance received, with unanswered claims counted as failures, gave the true figure of 65.8%.
How did you tell an enrollment problem from a follow-up problem?
We measured remittance coverage by payer, the share of billed claim lines that ever produced a remittance line. One state Blue plan had 4% coverage, which means claims were not being adjudicated at all, an enrollment failure. Plans above about 90% coverage were adjudicating normally, so their unanswered claims needed status follow-up, not enrollment work.
Did the client have to re-enroll with payers to change billing partners?
No. We work inside the client's own practice management system under its existing payer enrollments, as users rather than as a new submitter. No payer enrollment changed, so the transition was a single date-of-service cutover across every state and payer, rather than a sequence of payer-by-payer moves that would have left the book split across two processes.
Sources
Checked October 5, 2026. Rules change; confirm against the source before relying on them.