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 Fuchs,
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.
Thanks for having us. Thanks, Lucas. Yeah. I
wanna start off with introductions for our audience
that might not know you yet. Tim, we'll
start with you here.
Great. Thanks, Lucas. So Tim Fuchs, chief growth
officer
for Nimble, and I've been here for
nearly ten years and our organization
is a RCM company that has around roughly
1,200 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. So
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, and it's great to be connected with
you today. And 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. 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 health care 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 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. 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, etcetera. 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 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 wanna start off with you here.
Why is
accelerating
cash flow
so important right now
in the environment we're in?
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 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 don't 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 in a tight financially counseling process
too for those high deductible patients. So really
the outcome there is you're gonna have fewer
denials, faster payments, and less bad debt.
And then you really need to understand your
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.
Amanda, I I wanna dive into what Tim
just outlined a little bit more in terms
of the how, right, 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?
Yeah. And so that's a great question. And
and, Tim, that 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 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 and, standards
and
are their costs
being covered by their allowed amounts.
So they wanna 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
allowed 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 charge master 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 in
contracts, where the payers actually articulate in
the
billed charges
or the actual contractually allowed amount,
whatever is lesser.
So it's important to also perform routine charge
master analysis
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
kinda
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 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 the payer complexity
supporting the 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 upfront,
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 wanna 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.
Yeah. So many different things to pay attention
to, which I I'm glad you outlined, at
least of it just being, able to understand
all of this and understanding the contracts, right,
that you started off with, which is so
important.
Tim, I wanna shift back to something that
we started our conversation with, right, is we're
in this environment that is vastly different than
it was ten 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?
Yeah. Some of those factors are are really
interesting,
right now. Like implants and supplies, for instance,
are up eight to 20% depending on specialties.
Staffing and anesthesia,
we see a lot of,
this and and the Beckers updates on a
daily basis.
ASCs are really,
feeling
the highest wage pressure in industry right now
with this anesthesia piece
to ASCs.
And it's really challenging for them navigating that.
We're seeing technology and and compliance costs continue
to to go up,
and and ASCs can simply not afford,
some a slow billing process or slow AR
cycles with these increasing
areas that are really going up. So, and
then two, payers 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 to have their choices
between surgery centers and what they're doing,
looking at marketing, etcetera. So the the challenge
to bring in top talent is there as
well, and 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 operation. 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 wanna 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 up front 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. They're waiting for your data to come
out, really making sure that you're
jumping on that on a daily basis. And
then two, leverage outsource 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
to take that to the next level, whether
that's a pre certification team,
contract modeling as 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 an opportunity to get access
to a ton of expertise and technology that
sometimes they can't just justify by doing it
themselves. And there's a lot of that in
this ASC 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 ninety 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 ASCs to the next
level.
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 I wanna close
this out
with
your best piece of advice
for ASC
navigating
this uncertainty,
this space, all of these channel challenges that
we've highlighted throughout the conversation.
Amanda, I'd love to start off with you
here. What's your best piece of advice for
ASCs
navigating financial uncertainty right now? 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 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 thirty 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 wanna 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.
Tim, what's your, piece of advice?
I'd echo that too. I'd and 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 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.
Amanda and Tim, it's so great to have
you both. Thank you so much for being
here today. This was awesome. Thank you, Angus.
Yeah. Appreciate you having us. Thank you. Absolutely.
And we also want to thank our podcast
sponsor, Nimble Solutions. You can tune in to
more podcasts from Becker's Healthcare by visiting our
podcast page at beckershospitalreview.com.