Replaced the percentage with a like-for-like cohort
Method
- Same payer, same setting, same maturity: the only comparison that survives a charge master change and a mix shift
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Case study · Rural district hospital
Hospital collections rose 25.3% like for like. The collection percentage fell anyway.
Short answer: a rural district hospital with about 80 percent government payers posted its highest cash month in fourteen months while gross collection rate fell almost five points. The cash was real. The percentage was measuring a charge master change and a payer mix shift.
Full revenue cycle since Aug 2025Gross yield 12.41% to 7.63%Inpatient cash per visit $5,991 to $6,576Sep 2026 $5.14M · 14-month high
Edition
Oct 2026
Archetype
Rural district hospital
Horizon
14 months
Metric
+25.3% like for like
Payers
About 80% government
Length
6 min read
+25.3%like for like
Collections at 60 days, same payer, same setting, worth about $0.52M a month
+18.8%at 120 days
Still ahead at 120 days of maturity: more cash, not just faster cash
+72%Medicare
Cash per visit, $645 to $1,108
19 to 23%gross charges
Added by one hourly ER charge code on flat volume, with no cash attached
Fourteen months, from takeover to the board review
By mid-2026 cash was at record levels and the board was shown a falling collection percentage. Both were true.
- 1Aug 2025ASP takes over the full revenue cycle (excluding credentialing)
- 2CY2025Cash per month $2.92M
- 3Feb 2026One ER revenue code starts posting one unit per hour of stay
- 4Jan to May 2026Cash per month $3.87M, up 32.7%
- 5Jul to Sep 2026Average $4.90M a month; September $5.14M, the highest in 14 months
- 6Sep 2026Charge and yield review presented to the board
Cash
Record levels: $2.92M to $5.14M a month
Gross charges
+19 to 23% on flat volume from the hourly code
Percentage
Gross yield 12.41% to 7.63%
Cash upDenominator upPercentage down
From the hospital's own month-end report
Cash collected per month, hospital month-end report
ASP-RCM engagement records; every figure ties to the hospital's report, not our dashboard.$2.92MbaselineCY2025average
$3.87M+32.7%Jan to May 2026average
$4.90M+68% vs 2025Jul to Sep 2026average
$5.14M+76% vs 2025September 202614-month high
Monthly averageHighest month
Same payer, same setting, same maturity
Monthly cash can rise because volume rose or old claims paid late, so cohorts were compared at the same payer, setting and 60 days of maturity.
Medicare cash per visit
Jul to Dec 2025 cohorts versus May to Jun 2026 cohorts
$645Before
$1,108After
Medicaid managed care cash per visit
Same cohorts
$202Before
$328After
+25.3%At 60 days of maturity, about $0.52M a month
+18.8%At 120 days: more cash, not just faster cash
+20.4%Cash per visit, all payers
What the hourly ER charge code did, February to September 2026
| Line | Before | After | Reading |
|---|---|---|---|
| Units per inpatient account | 1.5 | 89 | one unit per hour of stay; r = 0.894 with length of stay |
| Gross charges on flat volume | baseline | +19 to 23% | $9.14M in September alone |
| Payability | n/a | not separately payable under per-diem or DRG | denominator up, cash unchanged |
| Gross yield | 12.41% | 7.63% | the percentage fell |
| Inpatient cash per visit | $5,991 | $6,576 | the cash rose |
| Denial write-off line per month | $14K to $132K | $1.5M to $2.4M | 97% were line write-offs on claims that had already paid, not denials |
Gross yield
Cash divided by gross charges
12.41%Before
7.63%After
Inpatient cash per visit
Same period
$5,991Before
$6,576After
Takeaway
Inpatient cash per visit rose from $5,991 to $6,576 while gross collection rate fell from 12.41% to 7.63%. The percentage measured the charge master, not the collections.
Payer and setting effects on cash per visit
Cash per visit by payer and setting
Medicaid rose from 46.3% to 50.6% of visits, about 359 more a month, a mix cost of roughly $144K a month.
Medicare inpatientper visit
$10,517setting is the largest lever
Commercialper visit
$1,397
Medicare outpatientper visit
$33331x lower than inpatient
Medicaidper visit
$19850.6% of visits
$0$2,500$5,000$7,500$10,000
InpatientOther payersGrowing share
Six moves, each tied to the hospital's own numbers
Took the charge-code finding to its owners
Charge master and ED
- Showed the length-of-stay correlation and the cash effect; the decision is theirs
Reclassified line write-offs on paid claims
Denial line
- 97% of the new write-off volume was not denial loss; it now reports as contractual on paid claims
Reported cash per visit by payer and setting
Board pack
- Medicare $645 to $1,108 and Medicaid managed care $202 to $328 on their own lines
Priced the mix shift every month
About $144K
- Shown as a mix effect so the board separates payer drift from collection performance
Anchored on the hospital's own report
Every cash figure
- Ties to the month-end report, not our dashboard
Reported as measured, not before
- NCRNet collection rate is pending the non-ERA feedA third of cash arrives outside electronic remittance; an ERA-only rate would understate it.
- 95%Coding accuracy has never been measured against the 95% service levelThe contract sets 95% accuracy and a 24 to 48 business-hour turnaround; turnaround is measured at about 27 hours, accuracy is not yet audited.
- ERThe hourly ER charge code is the hospital's decisionWe reported the effect on gross charges and the write-off line; whether to change the charge is a charge master question.
- 450The hospital-side ER charge detail has its own pageVisits, units per account and the share of gross with no cash: ER charge integrity.
Takeaway
Check the denominator first. When cash and the percentage disagree, look at the charge master before the billing team; report cash per visit by payer and setting, and let the percentage be a footnote.
Frequently asked questions
How can collections rise while the collection rate falls?
Gross collection rate divides cash by gross charges. One ER revenue code began posting one unit per hour of stay on inpatient accounts, 1.5 to 89 units per account, adding 19 to 23 percent to gross charges on flat volume with no cash attached. Gross yield fell from 12.41 to 7.63 percent while inpatient cash per visit rose from $5,991 to $6,576.
What does like for like mean here?
Claims compared at the same payer, setting and days since service, so volume growth, late payments and mix changes cannot flatter the result. On that basis collections were up 25.3 percent at 60 days and 18.8 percent at 120 days; Medicare cash per visit rose 72 percent and Medicaid managed care 62 percent.
Is the hourly ER charge code a billing error?
It is a charge master decision that belongs to the hospital. We reported its effect: a 0.894 correlation with length of stay, $9.14 million of gross charges in September alone, and a write-off line that was 97 percent line write-offs on paid claims. Whether to keep the charge is the hospital's call.
What is not yet measured?
Net collection rate, because a third of cash arrives outside electronic remittance and that feed is still being completed, and coding accuracy against the contract's 95 percent service level, which has a measured turnaround of about 27 hours but no accuracy audit yet.
Medicaid rose from 46.3% to 50.6% of visits, about 359 more a month, a mix cost of roughly $144K a month.
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