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Becker’s Healthcare Podcast
How ASCs Can Strengthen Cash Flow Amid Industry Pressures: Insights from nimble solutions
00:17:19
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- [00:00]
A
Hi everyone, this is Lucas Voss with Becker's Healthcare. Thanks so much for tuning in to the Becker's Healthcare podcast series. Fantastic to have you. An exciting topic today, Leading through uncertainty, how ASCs can strengthen cash Flow and stay ahead. And joining me for today's discussion, very excited to have them both is Tim Fusch, Chief Growth Officer and Amanda Whitener, Senior Director of Client Development, both at Nimble Solutions. Tim and Amanda, it's so great to have you. Thanks for being here.
- [00:29]
B
Thanks for having us.
- [00:29]
C
Thanks, Lucas.
- [00:30]
A
I want to start off with introductions for our audience that might not know you yet. Tim, we'll start with you here.
- [00:36]
C
Great. Thanks, Lucas. So, Tim Fusch, Chief Growth Officer for Nimble and I've been here for nearly 10 years and our organization is a RCM company that has around roughly 1200 clients in all 50 states. We grew our business focusing on the ASC market, but as we began to grow that, we started being asked to do the clinic side of things and anesthesia. We really focus on being an outpatient surgical RCM focused organization, being able to support our clients from an enterprise wide view, whether that's their surgery center, their practice, or their anesthesia group. We don't do acute care work on the hospital side. We really focus on that outpatient market. It's great to be connected with you today. We also have Amanda Whitener who is a Senior Director of Client Development here at Nimble. And Amanda, we'll let you jump in here too.
- [01:30]
B
Sure. Thank you, Tim. Thank you, Lucas. Yeah, as Tim stated, my name is Amanda Whitener, Senior Director of Client Development here at Nimble. Been in the RCM space and the healthcare space over a decade now. Most of that time being spent with Nimble. I love this industry. ASC is ever changing and working for a group that stays apprised of those changes and disseminates it to the industry accordingly is always just very exciting and very rewarding. I'm very blessed to be here with this group and looking forward to having this conversation today.
- [02:04]
C
One more thing really quick too. I should mention that we, our clients really represent every ownership structure in the ASC space. We work with independent groups, health systems, we touch most of the management companies and private equity firms, corporate organizations, MSOs, etc. So we've got about 20% of the ASC market in some form or fashion working with us. So we have a lot of great experience that we can bring to this.
- [02:32]
A
Conversation today and I'm excited to hear about some of that because we're going to touch on it for sure. And it's on in our title too of our conversation today, Cash Flow. And Tim, I want to start off with you here. Why is accelerating cash flow so important right now in the environment we're in?
- [02:52]
C
Yeah, absolutely. So yeah, with reimbursement pressure right now, rising costs and shifting case mix, ASCs can't afford to be reactive. So the centers that win are the ones that continuously monitor that financial performance. They pinpoint those issues early and adjust quickly. And here's a couple areas where they can really stay ahead. And I would say really focusing on data and understanding data, not just waiting a month to do it, but on a daily basis and understanding how to take that, analyze it and react to it is really important. You really should be looking at your daily cash and where that acceleration is coming from or where opportunity is to increase that. And you can do that by really tracking your denial trends by payer and cpt, your authorized versus unauthorized cases, cash per case by specialty. Really looking at your AR aging and then your net collection rate too is really important. And your outcome there is really that you're spotting revenue leaks before they become write offs. And another big part of that too is really establishing a tight front end process. 70% of downstream revenue issues start before the patient enters the building, which is a fascinating stat that a lot of people aren't aware of. So ASCs must have an automated eligibility and benefits review, really have a bulletproof process when it comes to authorization workflows and then having an accurate patient estimates and a pre service payment strategy because the patient is ever becoming a bigger portion of the payer and then a tight financial counseling process too for those high deductible patients. So really the outcome there is you're going to have fewer denials, faster payments and less bad debt. And then you really need to understand your case mix and your profitability by surgeon. So not all cases or surgeons drive the same financial outcomes. So ASCs should be tracking your profit margin by surgeon, your implant profitability or utilization, and really understanding your high cost outlier cases and breaking that out by specialty too. So you're really looking for that you can optimize your block time, renegotiate supply costs and really grow profitable service lines.
- [05:07]
A
Amanda, I want to dive into what Tim just outlined a little bit more in terms of the how and how we're doing this. Right? What are some of those strategies that you're looking at that you recommend ASCs adopt to then again accelerate cash flow to where it is profitable to what Tim just outlined?
- [05:28]
B
Yeah, and so that's a great question. And Tim, that was a great outline. I would say two key avenues to accelerate cash flow are developing strategies for managed care contracting and coding integrity. Those are two topics we speak on quite a bit. With regards to contracts. This is something we at Nimble place a huge emphasis on. We actually want our clients to be very knowledgeable with regards to their contracts. We engage with many ASCs nationwide and I would say a common denominator is they, well in fact around 95 plus percent don't have complete copies of their contracts when we initially engage them. Which immediately tells me a few things. One, their contracts are likely out of date. So that to me means less than par fee schedules which is a huge opportunity for improvement of cash by way of payer negotiations. Our clients should know, our facility should know where they stack up against industry standards and are their costs being covered by their allowed amounts. So they want to look at their Medicare rates, look at their fee schedules, perform routine case costing and they need to have their contracts to do that effectively. Two, if they don't have complete copies of their contracts, it tells me it's likely those centers billing teams aren't referencing the contracts when they're doing their day to day work. And this is so important. So one thing they may be doing like let's say they're posting payments, they may be applying a percent of medicare when confirming EOB payments or working ar. So that's if they know that the payers allow it a percent of medicare and if they know that percentage for each payer. But what about implant nuances? What about carved out case rates? Those two things, implants and carve outs have massive cash implications if not handled properly. And the team should have access to full contracts to know that level of detail when they're doing their day to day work such as AR or payment posting. The third thing it tells me is if they don't have complete copies of their contracts that their chargemaster could actually be out of date. And this is their fees that are their charges that are loaded into their practice management system. And this is where we run into a lot of issues with lesser than language and contracts where the payers actually articulate in the contracts that they'll allow the lesser of bill charges or the actual contractually allowed amount, whatever is lesser. So it's important to also perform routine charge master analyses to ensure charges are consistent across payers but sufficient to account for each fee schedule. Something else I mentioned is coding. Coding gives both an opportunity to maximize cash. So example Would be procedures that are dictated in the operative report but aren't appended to the initial claim. We see it, it happens. The other opportunity is to keep the cash the center gets by remaining compliant. So it's important to have your coding solution routinely audited. One coding mistake. I mean I'm sure everyone knows this one coding mistake could cost thousands of dollars. It seems. It seems kind of like a smaller issue. But even one misplaced 59 modifier. This is a modifier now, could lead to an inquisitive payer initiating a full on audit that could lead to costly take back. So making sure to have certified coders for each specialty is huge. Here at Nimble we have over 380 coders. Our coders are certified and we make sure we support every specialty. It's very important to have certifications for every specialty that you're performing. Finally, I would include, kind of to hearken back to what Tim was saying, just streamlined RCM processes from start to finish. Prior auths continue to be a talking point in our space with the payer complexity supporting the requirement for prior auths. So while we're waiting for changes in those requirements to occur, we need to be diligent in our front end processes. We need to know our contracts, obtain prior auths, sometimes for a range of codes, collect patient balances up front code what's dictated on the operative report. No more, no less. There comes that compliance. Keep charges consistent and pay close attention to the line item requirements such as NDC numbers for drug codes. We want to strive for 95/plus percent clean claims on first pass post payments based on contractual allowed amounts. You need your contracts to do that, follow up on AR until every penny due the center is delivered by the payer. You need your contracts to do that as well and have a great rapport with the patients on the back end so that you can continue to obtain any additional balance that remains which hopefully at that point isn't much.
- [10:15]
A
Yeah, so many different things to pay attention to which I'm glad you outlined. Least of it is being able to understand all of this and understanding the contracts.
- [10:22]
C
Right.
- [10:22]
A
That you started off with, which is so important.
- [10:24]
C
Important.
- [10:24]
A
Tim, I want to shift back to something that we started our conversation with. Right. Is we're in this environment that is vastly different than it was 10 years ago. It's changing so much. There's so many different dynamics that are happening right now. How can ASC stay on top of factors impacting their financial performance right now?
- [10:43]
C
Yeah, some of those factors are really Interesting right now like implants and supplies for instance are up 8 to 20% depending on specialties, staffing and anesthesia. We see a lot of this in the Becker's updates on a daily basis. ASCs are really feeling the highest wage pressure in the industry right now with this anesthesia piece to ASCs and it's really challenging for them navigating that. We're seeing technology and compliance costs continue to go up and ASCs can simply not afford a slow billing process or slow AR cycles with these increasing areas that are really going up. So and then two payors are slowing down on purpose. They're having more prior auth requirements, more clinical reviews, higher denial rates and longer reconsideration and appeal cycles which is making it really challenging for surgery centers to navigate those markets. So when we're looking at that and also too competition is fierce. New surgeons are going have their choices between surgery centers and what they're doing, looking at marketing, etc. So the challenge to bring in top talent is there as well. And so it's really this, creating this kind of perfect storm for really being able. The ASCs that can navigate that in a better fashion and do it with data can, can be more successful. So really accelerating your cash breaks this cycle before it harms your operations. So we want to make sure that you're really looking at all the areas that are going to impact this. So we're looking at financial education for not just you, but your surgeons. So you want to give feedback to those surgeons on case profitability and making sure they understand their costs and what, what we can do to streamline those cases to make them as profitable as they can be. You want to make sure that you're continually training your staff on documentation standards to prevent denials. A lot of that upfront work comes from making sure that those folks at the front end are doing a good job and doing that in real time, not waiting for the end of the month or waiting for your data to come out. Really making sure that you're jumping on that on a daily basis. And then two, leverage outsourced expertise when needed. I think there's a lot of great resources out there from the front end piece to after the surgery is performed to understand how you can utilize a specialized partner to take that to the next level. Whether that's a pre certification team contract modeling as Amanda's mentioned and those contracts and being so important implant cost management services. There's a lot of groups out there that focus on that portion of your business now and can make that really successful for you and then just maybe looking back and seeing you doing an audit and seeing where are the holes to increase the health of the revenue cycle. So centers can have the opportunity to get access to a ton of expertise and technology that sometimes they can't just justify by doing it themselves. And, and there's a lot of that in this ASE space that can really take them to the next level. So really just making sure top ASCs really run those structured financial reviews that cover revenue cycle, KPIs, payer trends, cash forecasting, case mix changes, your implant, spend your AR over 90 days understanding your high risk denials and then your underpayments. And so your problems are really identified early and those leaders stay proactive, not reactive and can take their ASC to the next level.
- [14:33]
A
And because this is so multifaceted, it's fantastic to have you both on because you bring, both bring so much experience and so many different aspects to this conversation. I want to close this out with your best piece of advice for asc. Navigating this uncertainty, this space, all of these challenges that we've highlighted throughout the conversation. Amanda, I'd love to start off with, with you here. What's your best piece of advice for ASCs? Navigating financial uncertainty right now?
- [15:06]
B
Yeah, I mean, I would say just focus on the fundamentals. When margins are tight, the little things matter. So you want to make sure your front end teams are supported and trained, that documentation is clean and authorizations are handled right the first time. When those things are solid, you're not just improving your cash flow, you're actually building confidence across your entire organization. So you can weather the noise. Noise because you know your processes are strong. Right. And don't be afraid to ask the ASC specific experts and listen to what they have to say. Anybody in this industry knows that it's very nuanced. It's different than hopd, it's different than clinics. It's, it's, it's very different. Even if you've been in the industry for 30 plus years, it continues to change. So knowing that there are specialists for each step of the revenue cycle as well as those who understand the payer landscape in a way that requires that dedicated attention to the way they operate, that's huge. So you want to lean on your resources that may have additional expertise in any area you may be struggling with. And you know, don't, don't be afraid to ask those questions no matter how long you've been in the industry.
- [16:14]
A
Tim, what's your piece of advice, I'd echo that, too.
- [16:18]
C
I and I'd stay proactive, as I've mentioned, not reactive. It's easy to feel like you're playing defense right now, but the ASCs that are thriving are the ones that stay curious about their numbers and data. And the ones that know their data are the ones that are ahead. They're watching their denial patterns, their AR days, their payer mix, and they're acting on those insights in real time. When you treat your data like a conversation instead of a report, you can spot the small issues before they turn into big problems. And honestly, that's what separates the good from the great. Those who use that uncertainty as a cue to tighten up, to innovate, and really to lead with intention. So those are the the advice I would give.
- [16:58]
A
Amanda and Tim, it's so great to have you both. Thank you so much for being here today.
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B
This was awesome.
- [17:04]
C
Yeah. Appreciate you having us. Thank you.
- [17:06]
A
Absolutely. We also want to thank our podcast sponsor, Nimble Solutions. You can tune into more podcasts from Becker's Healthcare by visiting our podcast page@beckershospitalreview.com.