Thanks so much for that introduction. I'm really excited to be here. AOE is a great organization that has some awesome learnings and educational, educational sessions. So be honored to be part of these, part of the speaking engagements here. So with that, let's dive right into the content. We're super excited to be chatting something near and dear to my heart, which is big on revenue analytics. So the kind of revenue analytics and how to keep actionable insights at your fingertips. So we've, we're joined by a very special guest today. So I'll let, I'll let Ethan introduce himself and kind of his role at a United Musculoskeletal Partners. So Ethan, if you don't mind, go ahead and give yourself an introduction. Yeah, absolutely. Thanks Andrew. So my name is Ethan Lyle. I am the chief revenue officer for United Musculoskeletal Partners. We're an MSO group organized primarily around the MSK space. I've got over 20 plus years of experience in healthcare, probably spent half of my time in the healthcare finance space. So I'm very deep into net revenue analytics. And then the last half of my career now, primarily in the rev cycle space. So I guess you could say a bit of an expert in the, in the field. And speaking with you now, my name is Andrew Harding. I'm the VP of customer success and one of the co-founders here at Ribbit Health. So I work with all of our customers, physician groups, and hospitals, kind of post-sale going through implementation, training, adoption, and hopefully eventual success using Ribbit's products. And then diving into kind of what we're talking about today. So the learning objectives by the end of this session, you'll understand how to properly analyze the why behind key metrics, that actually to increasing your revenue and some tips and takeaways on how to take immediate advantage of growth opportunities, all of using some of those key metrics. So we've got this split up into kind of four key sections. So the first one we'll go through is just your industry background, right? Some basic knowledge into who's doing what, how is this being done? What metrics should I be looking at? Then we dive into some of the advanced metrics to know and why. So really some of Ethan's specialties around the net revenue modeling and forecasting. And then look at some revenue analysis and how you can use that analysis to ultimately increase your revenue. And then, you know, I've said revenue a lot, but we will dive into the definition by what we mean into the kind of three versions of revenue and last but not least leave you with some immediate and actionable takeaways, right? What are the things that you should focus on immediately if you want to be able to take it back to your organization, your physician group, your, your hospital and take that follow on. So without further ado, let's let's dive in. So this first one, we'll kind of structure into a little bit of, of me talking and hopefully a lot of bit of Ethan kind of sharing his experience with 20 plus years in the space. And so I want to really ask you this first question, Ethan. So when you're building metrics, what do you typically see as your source of truth, right? How do you build these metrics? Who creates them? What is the process to create and, and distribute these metrics across teams? So we consolidate our data into our enterprise data warehouse solution. So we have multiple EHR platforms, primarily legacy moving into our predominant platform. And then we have various bolt on platform technology. So our data is kind of spread across areas. So we consolidate all of that data into our EDW platform and then leverage a front end solution where we're building reports, dashboards for us to use in rev cycle, as well as our clinic operational folks. Nice. And how is from the, that migration from legacy systems? What are some of the challenges that you've seen just with piecing a bunch of different data sources together? Generally, I would say that the most, the biggest challenge I would say I've seen in my experience is really getting to the data and then being able to ingest it. Normalize it. A lot of times EHRs either calculate things differently or have different levels of aggregation. So it's a, it's impossible to explode something out to a higher or a more detailed level of, you know, data versus the higher aggregated. So I think that's generally one of the bigger challenges. You know, there are some source systems where we just can't get to the same level of detail that we do in our predominant platform. So it kind of limits us in how we can look at things. Generally, that's been my experience is the most challenging. Yeah. Yeah. I totally agree. And you know, to your point on, are the systems saying the same thing? Are they calculating things the same way? That brings us to one of our first topics, which we call revenue versus revenue versus revenue. Right. And the amount of times I'll say revenue, you'll be sick of it by the end of it. But you'll know our definition for each of the three. So we think of there's really three levels of, of revenue kind of in descending order, but in ascending order, in terms of relevance and opportunity for that. So the first one we have is your gross revenue, and we define this as it is your bill charge. You may call it your charge master, your internal fee schedule, what ultimately goes out on the claim as the charge price for service. And you have that multiplied by the units that you build. So if you have a $250 charge price for nine, nine, two, and three, and you build 10,000 units, that is your gross revenue. Now, while this number is kind of running joke and physician land is, this is kind of funny money a lot of times is you own your charge master, most payers, unless you're on some legacy contract, most payers aren't paying percent of charge, especially in the professional space, it's kind of funny money that you're able to fabricate this gross revenue number, but you need to be consistent across all of your payers, right? It's best practice that you charge the same price to Aetna, to Cigna, to United, to Blue Cross. And the only time that it really becomes impactful, especially on the physician space is if you actually aren't charging enough. And that's where something from your contracts to take a look at is what we call the lesser of clause. It's pretty common knowledge and terminology in most contracts that will say as a payer, we will pay the lesser of your bill charge or your charge bill charge, or your contracted rate. Now, uh, you know, an example, let's say you have a contracted rate for a hundred dollars for a nine, nine, two, and three, if your bill charge is $90, even though contractually you're entitled to a hundred dollars, the payer can legally and in good faith and conscience pay you that 90 bucks because of lesser of clause. So in physician world, that is, that is the most common time that the gross charge or the bill charge really is impactful for you. So that's kind of revenue number one, right? That is your top line. What is your gross revenue? A step down below that is what we call contract revenue. And this is sort of a fabricated number because it's not going to show up in your gross or your net, but it's a way that teams like managed care can normalize a different. Pseudo net revenue rates. And we think of contract revenue as that same, you know, procedure code, nine, nine, two, and three at 10,000 units. But instead of the $250 charge price, our contract States, it's a hundred dollars. This is relevant and different from. Your, your actual net revenue, because it doesn't factor in all of those funny adjustments that happen throughout billing. So things like modifiers, multiple procedure reductions, and I should clarify modifiers. Typically we refer to that as soft-coded modifiers, right? Your 50 modifiers, your 80, 81, 82 AS modifiers, whereas your hard-coded modifiers like 26 and TC. It's common that those have their own fee schedule rate. Um, you know, so the contract revenue looks at, Hey, assuming no funny payer adjustments, these are my contracts. What I've negotiated with the payer multiplied by my volume that he was my contract revenue. And then the third level of that is what we call your real net or, or really just simply your net revenue. And this factors in not only your bill charge, right? Look, has to look at lesser of clause. It factors in your contracted rate associated with what is your uniquely negotiated rate between you as a provider and your different payers and insurance companies down to the fee schedule level, right? So it needs to determine between Medicare advantage. Uh, maybe you have a managed Medicaid plan, multiple commercial plans. Each one of those have a different reimbursement rate pretty frequently. And so the net revenue is going to factor in the, what was billed, what circumstances or conditions were met on the claim, and then what your uniquely contracted rate is, and then net out, say, Hey, assuming that you didn't have any denials here, you collected all of your patient responsibility. This is your highest opportunity for yield, right? Your net revenue number. So the net revenue is the, it really is the best cash forecast or cash positioning, positioning metric for your organization because gross revenue can be fabricated. It can be shrunk. It can be grown, but net revenue is ultimately, Hey, this is the most that we collect could collect based off of our unique circumstances and from a revenue number, the, it matters. As you think about your internal financial operations, how do you structure your organization? Are there's two key primary accounting methodologies. The first is probably the most basic and it's called cash-based where when you're recognizing revenue, you're looking at what got paid, what payments came in this month. And if you're collecting $5 million this month, that is what you're, you're booking or recognizing as revenue is the payments that have come in the door. Some of the pros of that is it is very simple. It's great for your smaller groups, but it's very reactive in nature, right? You don't know of that $5 million. Should I have collected 7 million is 5 million, like actually very good for us. And then contrast that to accrual accounting where you're booking revenue in advance. So let's say in any given month, you say, Hey, we generated $10 million of revenue. And then that $10 million may be at the gross basis, but then you go through your net revenue calculations and say, okay, what we are booking is a net revenue standpoint is $6 million. And then when the cash comes in, you start to evaluate what your collection rate is or your yield on that net revenue. And that's where some KPIs like, Hey, you should be collecting 95 plus percent of your net revenue comes in. And then the Delta that is your write-off rate, like, you know, sub 5% between bad debt and insurance write-offs. And so accrual accounting is more planning in nature. And obviously it takes a little bit more configuration to get that going because you need, you need some method by which you're booking off of build charges and build net revenue before the payments even come in. So those are just kind of helpful summary around the revenue, revenue, revenue, number, your gross revenue, your contract revenue, and your net revenue, and then some of your common accounting methodologies between cash based and accrual accounting to help you think about, well, where do we sit today? Where do we want to go? Are we cash going to accrual? Are we accrual, but we want to get more accurate. And then we'll talk in the next section about some advanced metrics. So dive into the next section, kind of pinging this one back to Ethan. You'll love to pick your brain on what are some of the monthly KPIs or key performance indicators that you look across, not only revenue cycle and to identify opportunities in rev cycle, but also general business performance. And where, where does your mind go with those KPIs? Yeah, I was thinking about this and I'm like, man, it's really hard just to pick, you know, a handful of metrics. There are so many different variables as we all know, throughout the healthcare cycle, I would say first and foremost, we look at our net collection rate. But you mentioned this a little bit earlier. So we leverage our, either our expected reimbursement from historical claims data, and as we've evolved, we've gotten more sophisticated and able to leverage the rivet data that actually uses modeled contracts to help us gauge what are we collecting based on truly what should we collect per our managed care agreements. And then secondly, you know, we want to make sure that it's important that we're collecting, but how quick are we collecting? So what's the velocity of that cash coming in? So typically we're monitoring AR days and then also looking at AR greater, AR greater than 90 percentage, just to ensure that, you know, we're not taking too long to collect those dollars. And then lastly, we want to understand kind of where is our leakage? Where are we leaving, you know, revenue or collections on the table? So we tend to focus on initial and fatal denials, initial meaning what's that first initial payer response and then fatal, what's that last resort where, you know, we've unfortunately missed out on our opportunity to appeal or was denied. So what is that percentage overall? And then lastly, we're also looking at what percentage of our patient collections are we collecting against total patient responsibility? So they're kind of the two areas of the primary leakage. And I'd say lastly, is, you know, one of the areas that we have focused on a lot over the last couple of years with our partnership with rivet is in the recovery space. So that's kind of the last, the metric that we look at if I had to pick like five or six. But there are a host of ones that we do look at on a monthly basis. Yeah. You can, you could build a whole scorecard for us on the fly. It sounds like, yeah, I really like, you know, obviously we're big on, on forecasting your net revenue and looking at your net collection rate. So, you know, definitely looking at that and then some of the aging, right. I think it's pretty common knowledge. The older balances get the higher risk they become and they lower the likelihood to collect. So those, those are two big ones that really stuck out to me. And, you know, what, what we look at from our perspective on the, on the tech and the vendor side of things is how can we help enable best, you know, the best forecasting methodology. So we look at, you know, one of the things that you've talked about was our net collection rate, which is, you know, typically how I define that is you have a net revenue and then what are you collecting against that as a, you know, as a total percentage. And, you know, that to start to actually calculate that you have to understand the real value of, you know, what can you collect where, you know, from an AR standpoint, what do you expect to collect? What's the value of it? What is, you know, we call it collectability. And then, you know, to your point about AR greater than 90 is the real value of AR as it gets older, it gets less and less, right. Because your most accounting teams or finance teams will start to build models against that and say, well, Hey, once an insurance balance is 180 days, you've probably had at least one denial, if not two denials, and maybe you're all the way at like level two clinical P2P denials. There's a pretty low likelihood that you're actually getting paid on that at this point. Um, you know, so real value of your AR can be really beneficial to track, especially as you're looking at metrics of aging AR and your net collection rate. And then your cash position. Yeah. That's another one that we've seen it ebbs and flows, right. It was in COVID era. It was some frightening times around cash positions for a lot of practices. And then even in, in early 2024, we saw some kind of crazy cash positions with, uh, with some of the software issues with clearing houses and some major payers not cutting ERAs being slow to adjudicate claims because 837s weren't being generated. And so understanding what is your cash position, not only days cash on hand, but what are you expecting from a cash? When are you expecting that cash as an organization or practice or a facility to help you plan for, you know, for future needs. And then strategically, I think if you can, as you're identifying where, you know, if you have any cost accounting in play and you say, Hey, these services, we attribute this, this X factor, this cost to those services. Hey, we have, you know, maybe your ophthalmology and you know, that your injections have a very high profit margin because of high dollar drug codes and the office component, if you're, you know, MSK, you've got some of those higher dollar surgical, right. The, the shift in, uh, in joint replacements from inpatient to outpatient to ASC, right, those are pretty high, high cash services for you all. Uh, and then, you know, you think you talked about some of the recoveries. One of the recoveries that we look at is, is underpayments. So you've got your contracts and you're legally obligated or contractually obliged, if you would, to receive that revenue from payers. And if they're not paying according to your contracts, you have the right to appeal those and seek reconsiderations or redeterminations. So if there's a discrepancy, you can push back on your payers, say, hey, we were contractually entitled to this revenue. You paid us here, you misapplied a modifier, the provider was being paid at the wrong rate, we need these to be reprocessed. So discrepancies on the payment side can be a high ROI opportunity. Yeah, I'll just mention a couple of points I'd say, you know, in talking about modeling your contracts and monitoring that, it's been interesting. I've seen many times throughout my career where payers inadvertently forget to load an updated fee schedule. And so, you know, they're paying you based on they've missed an escalator that's in your contract. So it's not uncommon to find those. Those are the big wins that you have generally when that happens. But without, you know, a solution in place for you to detect that, it's really difficult. And then just the other point too on, as you look at your net collection rate, I would say, you know, just thinking about the source of that data, if you're not able to use modeled or expected reimbursement, be careful about measuring yourself against maybe poor performance. So, you know, if you're running a fatal denial rate of, you know, three or 4%, and you're measuring yourself against that, and are you collecting 97 or 100%, you know, you're measuring yourself probably not against best practice, we're targeting, you know, less than 2%, generally around 1.5% in fatal denial rates. But it's not uncommon to encounter practices that are much higher than that. So you have to be cautious about measuring yourself against, you know, maybe not industry best practice. Yeah, yeah, that's a great call out. You know, I like to golf and I always give people a hard time when they sandbag on their handicap index. And they say, you know, it's easy to beat your handicap when it's not a good performance number, right? So very similar to your call out there of don't measure, you know, don't benchmark against poor metrics or poor performance or poor, maybe it's just periods of the year that you had poor performance. But yeah, great, great call out. And that's one thing that takes us is getting into the shift of like, how do you know what revenue? How do you know what's good? How do you know seasonality trends, right? We know that throughout the year, there's lots of shifts. So like, here's an example of, hey, this solid kind of purple bar, that is the gross revenue. And of that, we pull, to your point, a forecasted revenue number based on performance, really, which is, what do we think you should be, based off of what we're contractually entitled to, the conditions met, right, modifiers, who's rendering the service? Do we have a shift in more PAs or nurse practitioners billing services versus, you know, MDs and DOs, right? You spit out a target and you're trying to collect against that target. Here's that kind of purple and orange lines and say, hey, relative to our forecasted modeled or booked net revenue, what are we actually collecting? How does that, how's it distributed across, what are our payer receivables? What are our patient receivables? And that all gets thrown into a model. So kind of pick your brain one more time here on the Ask the Expert is, what pieces need to be in place for you to accurately model out your expected net revenue? Kind of, what are the pillars of success there? And to do it, to your point, accurately, right? Not necessarily measure bad performance. Yeah. You know, I would definitely say the ability to get to your fee schedules, you know, not having a solution, say like a rivet. I can remember back in, you know, my days of having to do this manually via Excel, trying to create an access dashboard, you know, so one, just being able to have the data in order to calculate your expected reimbursement. But then you'd also be surprised at the times we encounter where we maybe don't have all the managed care contracts we acquired from a practice. So they don't have the contracts and they just have fee schedules from payers. And you'd be surprised how many times that once we do get contracts and start to compare those fee schedules against the actual language of the contract, they don't match. And so it definitely is important to actually have your managed care agreements, be able to read that methodology, the language within the contract to accurately model those rates. Yeah. The contracts are a fun one. And I mean, we've heard groups, it's getting harder to get in touch with people to gather your contracts. We know there's some transparency data available in the market. So for those that haven't heard of transparency and coverage, it is guidelines or regulation, I should say, that requires payers to post their machine readable files of all the contracted rates, all the in-network contracted rates and out-of-network historical allowables online. So if you're not familiar with who your payer rep is, maybe you have to go through a portal, maybe it's Cigna for HCP, UHC provider, a lot of them are through Availity. And to Ethan's point about, you got to get your contracts and you got to know what you're entitled to receive before you really do any revenue modeling, you know, that's a great place to start. Either go through the payer portals or look for vendors that have access to those payer machine readable files and at least start there, right? You can benchmark and say, this code is per the payer file is this rate. It's this percentage of Medicare, right? You trigger that through the rest of the fee schedule. It's a good starting ground, but, you know, we recommend if you can get in touch with someone at the payer, especially if you're going around negotiations, if it's been a handful of years since you've negotiated your contract, there's a good chance it's ripe for at least bringing it to the table, right? There's no guarantee that you're going to get a three, a five, a 7% increase, but you can at least have those conversations. And if your contract uses CMS as a baseline, then updating that CMS rate from maybe a 2018, 2019 to a more current rate, you know, that CMS factors in the sustainable growth rate to kind of allow for inflation, increased costs, and so it may be advantageous to you based on your procedure mix to shift to a more recent year of CMS baselines. So, you know, something that you can look at from modeling, modeling some of your net revenue, and then at the end of the day, get to some of your, your collection and yield. So that middle one, Ethan talked about the net collection rate, right? The percentage of cash you actually record as a percentage of your total net revenue, kind of your best possible net revenue. The gross collection rate is, it's interesting to look at, not necessarily because it's even all that helpful from a finance standpoint, but it's consistent until you change your charge prices. And then, you know, you might go from a 40% gross collection rate to a 50% or down to a 30%, but it happened because you changed your charge price. So there's not a real standard, especially in physician land where it's like, oh yeah, your gold standard is 40% gross collection rate, but generally in like that 40 to 50, maybe on the high end, 60%, it allows plenty of opportunity for contractual adjustments so that you're not losing any money from a lesser of standpoint. But if your gross collection rate is like 10%, 15%, it just means that your charges are so much higher than what most of your contracted rates are that you're adjusting off contractually, you know, 80, 90%. So again, not necessarily a bad thing, but in a more competitive landscape with more pricing, transparency and patient consumerism who may call and say, Hey, what do you charge for an MRI, a CT scan? What do you charge for this? It's just something to keep in your mind is how you can keep your net revenue while potentially reducing some of your total charges. And then the flip side of your net collection rate is looking at your write-offs. So categorically write-offs I define as two things. The first are your actual insurance write-offs. So Ethan had talked about fatal denials, things that ultimately are are denied or zero paid, and then either zero follow-up and you ultimately write it off. You don't have the ability to follow up or appeal this, or you've appealed it, but the payer upheld their decision. And it ends in, Hey, we've, we got to take a loss on this claim. Like those are really impactful. Um, mostly because it's typically a true zero pay. So your provider is rendering services and getting zero in return. So if you comp providers based off of production and RV use, you're paying the provider and you're not bringing the cash in on the backend. If you pay providers based on cash collected, then, you know, they might have some little questions on, Hey, why did that surgery not get paid? And now I'm not seeing, you know, the benefit of that service. And then, uh, the second component to write-offs is looking at bad debt. So bad debt is really your patient write-offs. So as you go through and the balance drops, right. Going back up a few slides to, uh, that cash forecasting one, right. This example has of the total net revenue. The purple is the payer responsibility and the orange is the patient responsibility. So that fluctuates throughout the year. It's typically a little bit higher in January, February, and March as deductibles reset, and then it tapers down as a percentage of total net revenue in October, November, December, but looking at what you're able to collect on that. And what you're not able to collect ends in bad debt, right? You may go through an early out collections process. You may ultimately send it to a third party, bad debt or, uh, or a collection agency, but at that point, at that point, it's written off of your books. You've basically assumed that you're getting $0 for it and any dollar that you bring back from the collection agency is, uh, is beneficial. So those are like the key metrics on collection and yield, which are gross collection rate, GCR, your net collection rate, NCR, and your write off. And then thinking a little more positively than write-offs, we'll look at timing your cash payments. So one of the things that is, is helpful to extrapolate from both historical performance and just the revenue that you're generating when you book that revenue on a cruel basis. So say in a specific month, you book $10 million of revenue. And that $10 million represents $6 million of debt revenue opportunity. When are you going to collect it? How long does it take you to collect it? And so this is a pretty straight line that, you know, over the first four months, you're going to collect the majority share of that $6 million. And then it tapers off and really flat lines because you're collecting very, very few incremental dollars in months, six, seven, eight, nine, 10. Right. So the steeper your cash curve can be, the better you're going to be for an organization. And you know, the, the metric that Ethan had mentioned a few minutes ago was your AR over 90. Right. So that is typically defined as from 90 days, most groups use a date of service. So 90 days from your date of service. And so that's three months after, and then post 90 days, it gets riskier and riskier every single month. And so if you can steepen that cash curve and you're collecting the majority in the first 60 days, right. Through both adjudication cycles and, and patient payment cycles, it's going to be really advantageous. It's going to keep healthier AR. It's going to allow you to work down some of the backlog or the tail end of that, that AR over maybe 120, 180, that's extremely at risk and bring it all towards a little bit more current. Yeah. So that is, we define as a cash curve that'll help you kind of assess how quickly are you collecting based off of the months that you've booked revenue. And then maybe the last little thing I'll talk about here before talking through some tech stack and some additional opportunities is how do you identify shifts in your revenue and what causes those shifts? So one of the obvious ones is, is anything changing between your payer mix? Right. Right. Typically your commercial payers, unless you're maybe in Florida where commercial carriers are really competitively priced relative to Medicare, typically your commercial carriers are your highest and they sort of subsidize or offset some of your Medicaid and maybe Medicare payments that are just a little bit lower than your traditional commercial payer. So if that balance goes from, you know, high commercial with maybe 30% Medicare and 5% Medicaid or 10% Medicaid, and then your Medicaid population shifts up or your Medicare population shifts up, but your best commercial rates shift down, that payer mix is going to cause a new imbalance in what your revenue is generating. And so you may have to reforecast and say, is this a long-term change? And it reforecasts what you expect your net revenue is going to be, which in turn makes some budgeting decisions. Kind of the second major shift we see is procedure mix. So this is, you know, a little bit more acute on the inpatient hospital where things like your case mix index can be really, like, can be drastically impactful because it changes your DRG weight, your length of stay, the cost to, you know, cost to administer care. On the physician side of things, if you're fluctuating between, Hey, we, you know, we closed an ASC, now we're doing more office visits and less surgical, surgical services, or there's an infusion clinic and that, you know, that opened up and that's a lot more profitable, those things are going to cause shifts in your recognizable, your net revenue, because they have different cash weightings associated with them. And then the last shift is it's just the underlying reimbursement changing. So, you know, if you've got contracts that use, we call current date CMS. So, you know, they just follow and say, Oh yeah, we pay 120% of Medicare rates. When Medicare changes their fee schedules or they change their, the RVU is associated with that, or they change the conversion factor or even change their geographic practice cost index index, their GPCI and your payer says like, great, we do whatever CMS does. Then those shifts may have unintended financial implications behind profitability margin and just your average revenue per encounter. Um, so going back to what Ethan said on, Hey, start, make sure you have your contracts is also know when your contracts are shifting, are they using CMS baselines or are they tied to a fixed period that the payer has to provide an updated amendment that you have to agree to before that new fee schedule goes into effect, could help mitigate some of those unplanned reimbursement shifts. You know, and I just look at, uh, you know, in 2024, early 2024, right. If you've, if you've noticed CMS went and did a re-forecast of their, uh, the Medicare rates. And so they have a 2024 a and a 2024 B where they increased the conversion factor. So if your payer pays to the first eligible version of Medicare, that was like a three and a half percent decrease in reimbursement across the board. And then they came back up and, you know, increase some of those rates, but you may have seen some unintended revenue impact behind those payers using current date CMS, but using the first version of it. Um, so we're kind of waxing long on the contract piece, but is near and near to my heart on knowing not only what your current rates are, but what shifts in the market are going to change your underlying reimbursement. So kind of the, the next section we have here queued up is, you know, revenue analysis that actually leads to increased revenue, which is ultimately the goal, right, is building not only models, but taking action plans around, uh, increasing your revenue. And so, you know, you tend to pick your brain a little bit, given that you talked about the, uh, how, how UMP does things. What are the biggest gaps that you typically see in the tech stack that make it difficult to produce these types of metrics, both, you know, maybe revenue metrics, as well as rev cycle metrics? I would say typically in my experience, it's generally, uh, the biggest challenge is either to spare platform. So, you know, um, in our space, we were transitioning groups to a common EHR platform. So we have, you know, legacy AR platforms. And then in addition, we have, uh, bolt-ons where we're leveraging, and there may be data stored in those that we need also to get a complete picture. So generally having data scattered across various, uh, disparate platforms. So bringing that together in an EDW definitely helps. And a lot of times though, it is challenging in organizations. They just don't have the ability or the expertise to, uh, be able to, uh, capture or ingest large volumes of data. Um, so generally that's one of the challenges I see. Um, and then having a solution to be able to create, um, actionable dashboards or reports, uh, leveraging data across those platforms. Yeah, nice. And I, I know, I think, your large tech stack is Athena with Snowflake. And we see those types of systems. And this is a pretty common example of certain tech stacks that we run into all the time, where most of these on the left-hand side are your ambulatory or physician practice management systems. And then a lot of times, you have some data intermediary or data layer on top of that, whether it's Snowflake or Databricks or Redshift database. And then we still see at the end of the day, like, those are much more technical in nature, right? Tableau is more of a business intelligence solution that has the graphical layer on top of it. But we see so much of it translates from, hey, we need data from claims, from our PM system. We need to flow it into our data warehouse. And then we need to be able to produce quick, nimble reports that are easily dropped into Excel. And I'm like, for one, I'm a lifelong Excel fanboy and use my Alt key like a champion. But it's limited. And there's a lot of opportunity for failures in that shift from data warehouse to Excel and how actionable that data really is. How do you drill down? How do you modify things? And so we think of pillars of a strong tech stack and then some of the pitfalls against that, one being, how frequently does the data actually flow in? Is it a day behind? Is it a week behind? Do you have to do manual pulls? How frequently are you getting core data into that system so that you can report on updated trends? And then from there, if you were pulling from a, you mentioned multiple PM systems at this point, how do you get it all to map to the exact same things? Even, I'm very familiar with Epic and even on Epic, they have different terminology for PV versus HB. And then let alone, like, is it a table space? Is it a context ID? Is it a site ID? Is it a patient number or a person number or a patient identifier or an account number? And taking all those variables and values and aggregating so it's all the same, right? It's an apples to apples comparison. And then from there, how easily can you actually create and distribute reports and then trend those out, right? Because a report in a single month typically isn't super helpful unless you're just looking at a bottom line number to see, is that good for us? Is that bad for us? Are we trending up or down? And so we kind of think of the four A's of reporting as actionable, automated, available and accurate. And those have just been like seared into my brain since founding Rivet in that a data should help tell a story. Data alone is pretty insufficient unless you know what you can do with it, what it's asking you to do with it. And then the automated piece is, in that first bullet is like, how quickly is data getting through? Does somebody have to manually push data? Is it getting automatically updated on a regular basis that is fully trusted by all parties? And then how available is it? So if we have to go through and every time you wanna report, you have to put a ticket in and then you have to go and you've got a queue of developer tickets to get that process like, right? It's not super available, you're gonna be delayed. And by the time you wanna see that metric, it's maybe the time has passed. But then paramount to probably everything is you have to be reporting on accurate metrics and more catastrophic than not automated and not super readily available is, I think the only thing worse than no data is bad data. You've probably heard some of that phrase is if something is misguiding you through your operations and you choose, you make business decisions based on that inaccurate data, a lot of unhappy people there. So we think just kind of cycling through a good better best from a benchmark standpoint of your revenue is bringing everything we talked about from what are some of the KPIs on collection and yield and what are some of the revenue reports is like, what is your basic, right? If you're like, you're blind looking at collection rate, it's like, great, started just cash to gross. That's it's the easiest to calculate. If you have no reporting, then there's a good chance you probably haven't updated your charge prices in a really long time too. So it's an okay litmus test for where are we at? What's good, what's bad? Are our charge prices too low? I'd consider it at risk if your gross collection rate is like 80 to 90%. Like that's really tight margin there. Then you step up a little bit above that and say, all right, what's better? Well, GCR is still a relevant metric. It's not our favorite because an NCR net collection rate is a lot better relative to what you can actually collect. But taking that a step further and apply it to the specific payer or fee schedule level. So if you've got Aetna's GCR is this, Blue Cross's GCR is something else, you can start to see shifts payer by payer. And it's just one level above where you're at from just blanket statement, hey, we collect 40 cents on the dollar. And allows you to be a little bit more stratified across your payers so that you can say, well, what did we build last month from Aetna, Cigna, Blue Cross, Medicare, United, and then forecast out and say, okay, we've got a 45% gross collection rate with Medicare. We have a 55% GCR with Cigna, a 60% with Aetna. And you just go down the list and it gets you slightly more accurate. But then the shift to the better is when you apply a claim or line item expected reimbursement. So we've got to build this engine that it brings in the 837 and a recent kind of more recent changes when the 837 comes in, we're going to price that right away. And we say, you build a $2,000 claim based off of the codes, the provider, the facility, the locality, the modifiers, where there are other services on the claim. We know that that represents $750 of net revenue. And then when the remit comes back, if there's any additional information from the payer that's provided, maybe you accidentally registered them as a commercial carrier, or a commercial plan, but they're on a Medicare Advantage plan, then you can bring that back and we reconcile or true up and say, oh, we now have more information. Instead of 750, they're allowing $600 because it's not commercial, it's Medicare Advantage. So those are what we consider truly kind of the best revenue benchmarking standards is every single time you build something, you have the gross and the net allowable. And then taking it a step further conceptually, which is, hey, do I know, is this claim going to Medicare, which they're going to pay me in two weeks? Is it UnitedHealthcare in February of 2024, where they're going to pay me in six months? Is it Cigna that they tend to pay you in about 10 business days? You can allocate that off of your cash curve. And then, wrapping up what Ethan had mentioned about what revenue are we losing? I think you obviously talked about fatal denials and write-offs is, you know, we call that what cash is walking out the door, right? Where is it sitting from an initial denial rate and then your recovery rate? So the recovery rate is a little bit harder to calculate, but how we think about this recovery rate is, let's say that your initial denial rate is 9.4%. Of that, you're hoping to be able to work or get to a large portion of those percentages. And then, if you're able to get to 90% of them, when you appeal those, what is your resolution effectiveness? And maybe you're only at 47%. Maybe you're at 87%. Maybe you're at 20%, because you're just like, yeah, we only pick and choose the very high dollar ones and, you know, they're rarely successful. So we look at the average recovery rate to determine, like, relative to what's being denied, what is actually walking out the door. And then from there, you can start to stratify into different risk portions. And then we also look at, you know, you see this table down below is an example of comparing your payers across each other. So you think like, well, who is my highest and lowest denying payer, right? From a time to pay, who pays me really quickly? Who doesn't pay me really quickly? If they have a really high denial rate, do they, you know, we see a lot of times, like in this case, Humana has a much higher denial rate, but they have a like somewhat high recovery rate. You know, it's stratifying your payers to get to the healthiest AR picture that you can. And then kind of wrapping it up here with when we consider things risky. So the first thing I want to touch on is, I get asked this a lot when I drop the word reserve calculations. So it's a really finance accounting heavy term, but it's basically booking revenue against your collectability. So let's say that you have an accounts receivable balance of $50 million, you are not collecting $50 million, right? If 30 million of that is in days one to 30, great. You may think that of that $30 million, you're going to collect 29 and a half million. But of, you know, let's say 180 days plus is $5 million, you might only collect two and a half million dollars. And so where you build these reserve models is start to say, relative to the age of our AR, what do we think we're actually going to collect? And then the older it gets, the higher the reserve rates. So it goes from the day it's billed is probably a sub 5% reserve rate, until day 365, it's probably reserved at 90, 95, maybe, you know, from a finance standpoint, maybe even 100% reserved. And like, yeah, it's a year old, you don't think we're going to get anything. So that is reserve calculations. And it helps you value the real value behind your AR to know like, all dollars on your AR are not created equal. A dollar that's one month old is a lot higher value than a dollar that's 365 days old. And then, you know, the two biggest risk populations looking at aging payer AR and an aging patient AR, you know, the payer side of things talked about, the older it gets, the less likely it is to be recovered. Maybe a payer doesn't even have a claim on file and it's just sitting out there, look for those no claim on file reports. And then the patient AR, right? Typically, if a patient doesn't pay by the second or third statement, their likelihood to collect just plummets to near zero. And then you're going to have, you know, potentially early out collections or bad debt collection vendors. So thinking through just real quick, some ROI opportunities in, you're looking at, what are some low performers in the industry? And if you've got a 15% denial rate, honestly, that's pretty high. And you're, if you want to recover that, you're spending a lot of time, I should say a lot of resources trying to appeal that high volume of denials. So you're looking at, you know, like $4.5 million if you're billing out $50 million a year at a 15% denial rate and you're only recovering 40%. You're looking at $4.5 million of net revenue kind of walking out the door there. You know, and so you just move through that, like industry average, we see about a 10%. And then, hey, you know, pretty high performers, like 8%. If you can get to sub 5%, you're like, great, thumbs up on your additional denial rate. And then you look at all the more efficiency metrics. So how effective are you at recovering denials? Are you at 40%, 55, like 70% of all denials? And then you look at, you know, how much are getting appealed and successfully paid? That's a pretty good metric for you. And then that trickles through the rest of the model, which is, you know, complete write-offs, what is ultimately a balance billable to a patient, right? Some insurance is depending on the denial. If it's like a coordination of benefits denial and the patient failed to provide updated information, in some cases, you may be able to transfer that to the patient and then ultimately yields in your write-offs. And then, you know, if you can get to sub 2% write-off rate, you're doing really well. So those are some of the KPIs that we've just seen, you know, pretty consistent throughout the industry. And, you know, last but not least, finishing this section up with a full recap and full circle into, you know, what are the benefits of the new model? And then, you know, Full recap and full circle into a process around modeling your revenue, determining what's better for your organization. Is it cash or accrual? If you're a small group, probably makes sense just to be cash-based unless you have a loan or bond covenants that require accrual booking, then like you kind of have no choice in that case and you got to book out your gross and net revenue and time your net revenue on a recognition standpoint. And then recap, you know, Ethan said collecting the insurance contracts, that'll help you figure out exactly what you need to do. Evaluate your historical collection rates at least as a benchmark, right? Not necessarily because that's your gold standard, but you want to be able to improve off of those. And if your, you know, net collection rate is 90% or 85% right now, you don't want to be there. You want to improve on that and drive, you know, drive improvements. And then, you know, how do you want to do that? Where can, what's your biggest bang for your buck to eliminate or reduce your opportunity costs and spend money and resources where you're going to have the best returns? So kind of the last little section here and wrap it up for a Q and A. So Ethan, I'll turn to you for this one. You know, what is, this may be a, I don't know, a tough one given the breadth of KPIs that you could look at, but if you had like one recommendation for anyone in a revenue cycle to triage, you know, going back to opportunity costs and you can only do so much with your team, you need a high ROI. Where would you start? How would you assess that? What would you recommend? Yeah, I think you touched on really most of it. It's looking at, you know, those leakage points and which one do you have the highest opportunity in. So to your point on either, is it an initial and fatal denial? So, you know, if your fatal denials are low, but you have a high, you know, percentage of initial denials, you're spending a lot of time having to solve for those. So, you know, there's potentially excess costs there that you can take out if that's the gap, even if you're successful in winning those denials. But, you know, what's your ultimate leakage point? Is it in those fatal denials? Is it in the patient responsibility collections or is it in the underpayments aspects? So I think it's looking at where your largest opportunity is and really starting to dissect it. You know, as we look at fatal denials, we start at, you know, at the top and look at what's our largest category of fatal denials as we categorize those CARC and RAR codes. And then just really started dissecting and looking across the organization. Upstream, you know, how do we impact those processes potentially that are driving those initial or fatal denials and how do we solve for it upstream so that we don't impact those in the back end? Yeah, that's awesome. And I'll kind of leave this session with, you know, the reminder that it's always leaky bucket, right? There's pinholes, sometimes there's gaping holes. And we know that at this point, looking at denied revenue, underpaid revenue, that you may have done nothing wrong. The payer missed your COLA, your cost of living, and, you know, didn't get your one, your two, your 3% for the multi-year contract. Like, are you billing from your charge price? Are you actually billing that out appropriately so that you're capturing that contractual revenue? And if it's been, you know, more than a couple of years since the last time you've chatted with your payer, A, like recommendation is start to try and build relationships with your payers. You know, if you get the glorious payer rep, which is so difficult to find these days, but if you get a good payer rep that can help you, that you can kind of riff with them between, hey, we want to be good providers in your network, we want reimbursement, right? That may be an opportunity. And, you know, and last, that last little kind of bottom right is, you know, if you've ever undertaken a revenue integrity product or project from, hey, are we capturing the charges that we're doing? Are we optimizing these charges? You know, along that property and bell curve that's appropriate for our specialty and our providers and our historical billing kind of cadences, there's can be some opportunity from a revenue capture standpoint that you may not be thinking of. So with that, we'll kind of turn it to Q&A and yeah, I want to thank you all for listening to this. So thanks so much. Got a cut. Great.

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