When the new ownership group acquired the seventh clinic, the legacy billing vendor went silent. Six weeks later, AR days had drifted to 50, three payers were sending recoupment letters, and the parent company finance lead opened the conversation with: "We don't know what's billed, what's paid, and what's lost."
01 / The starting pointThe starting point
The first 72 hours of the engagement were diagnostic. A senior ASP-RCM partner pulled the last 90 days of 835s, the active prior-authorization log, and the AR aging report by clinic.
Three findings made it onto page one of the gap report:
- $640K of recoverable AR sitting in the 90+ bucket, primarily on Medicaid managed-care claims with documentation-gap denials
- 32% first-pass denial rate across the network, driven by three CARC + payer pairs
- Authorization expirations running 14-28 days behind on roughly a third of active clients
02 / DiagnosisWhat was actually broken
The previous vendor wasn't lazy, they were generic. They ran the same scrubbing rules, the same denial-followup macros, and the same auth-tracker spreadsheet across every client regardless of payer mix. For a multi-clinic ABA group with 60% Medicaid revenue, that meant none of the payer-specific rules that drive ABA reimbursement were in place.
Three structural breaks:
- No payer-specific medical-necessity templates wired into the EMR
- Auth tracking lived in a single spreadsheet that nobody owned
- Denial rework happened claim-by-claim, with no Pareto on root cause
03 / The playbookWhat we did
Rebuilt the auth workflow
Daily payer-portal sweep + unit-utilization dashboard. Every active client visible, expiration-aware.
Pareto on denials
Top three CARC + payer pairs identified. Each routed to a workflow fix, not a rework queue.
EMR template lock
Payer-specific note templates with required fields enforced before claim release.
Aged AR triage
90+ day AR worked by overturn probability, not dollar value. Highest-yield first.
Front-desk eligibility
Real-time eligibility verification at every check-in. Cut intake-driven denials by half.
Weekly KPI cadence
One owner. Five KPIs. Reviewed every Friday with the finance lead.
04 / TimelineHow the 120 days unfolded
05 / OutcomesThe numbers
The first thing we noticed wasn't the cash. It was that I could finally answer the question 'where are we' in finance review without three days of data-pulling.
06 / What stuckWhat kept the gains from drifting
The recovery itself was the easy part. The harder part was building the operational discipline that prevented the same problem from re-emerging six months later. Three things stuck:
- One named owner for the weekly KPI dashboard, visible, accountable, with budget
- Payer-specific templates in the EMR, not optional, not bypassable
- Top-3 CARC review as a monthly ritual, with clear root-cause assignment
The engagement transitioned from project mode to ongoing partnership at day 120. AR days have stayed under 35 for the eighteen months since.