#183 How Multi-Location Practices Lose Revenue Between Sites, Part 2

Part 2 of our multi-location revenue series. If you haven't listened to Part 1 (EP182) yet, start there — the systems in this episode build directly on what we covered last week. 

EP182: Click here

Today we cover the two structural problems that let the Part 1 gaps stay open: front-end data inconsistency across sites, and the one role that either holds a multi-site practice together or lets it fall apart. 

System 3 — The EHR and Billing Disconnect: 

Different front desks develop different habits. One site verifies eligibility morning-of. The other verifies the day before. One collects copay at check-in. The other sends a statement after. A practice doing $120,000/month at Location B with a 20% authorization miss rate sends $24,000/month into billing with incomplete data. Some claims get caught in scrubbing. Some get denied. Some sit in a gray zone no one can explain at month-end review. 

Front-End Gap Reference: 

• Authorization not captured → Denial or recoupment post-payment 
• Insurance not updated at visit → Claim sent to wrong payer 
• Copay not collected at check-in → Patient AR that rarely converts 
• Eligibility verified day-of only → Coverage lapses missed pre-visit 

System 4 — The Office Manager Problem at Scale: 

Location A has a strong office manager who has been there since the beginning. Location B has whoever was available when the site opened. The metrics look similar on paper. The difference shows up in the denial rate, days in AR, authorization miss rate, and the number of times the billing manager has to fix something that should have been caught at the front desk. A $90,000/month site with an underperforming office manager loses an estimated $8,000 to $15,000/month in avoidable billing delays. That is $180,000/year from one seat filled with the wrong person. 

Three actions this week: 

• Audit front-end protocol consistency — pull authorization miss rate and eligibility verification rate by site 
• Run a site-level office manager assessment — KPIs only, not by feel 
• Schedule weekly site-level KPI reviews — separate meetings, not consolidated 

Episode breakdown: 

00:00 Series callback: the gap the report will not show you 

02:00 The thread left open in Part 1 

04:30 System 3: The EHR and Billing Disconnect Across Sites 

08:00 The $24,000/month authorization miss scenario 

11:30 Who owns the front-end protocol fix 

14:00 System 4: The Office Manager Problem at Scale 

18:30 The $180,000/year gap from one wrong seat 

22:00 Who owns the accountability structure 

24:30 Three actions this week 

28:00 Free resource + next episode tease 

Resources Mentioned 

Payment Posting Audit Checklist (free): 

eligibility.natrevmd.com/payment-posting-checklist 

Practice Revenue Leak Scorecard (free): 

eligibility.natrevmd.com/nrm-revenue-scorecard-v3 

Book a free 30-minute audit call: 

calendly.com/heather-natrevmd 

RECOVER Diagnostic Quiz: 

natrevmd.com/quiz 

EP182 — Part 1 of this series: 

Link here

Transcript

SPEAKER_00 0:05

Last week we covered two revenue gaps that are hardest to see inside multi-location practices. We talked credentialing blind spots and that shared billing problem. Those two gaps can cost over $200,000 a year from damage that never appears on a consolidated financial statement. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. And so we talked about the GAP report, and this week we're going to talk about the systems that you can layer on top of this in order to have the right data and the right individuals accountable for each of your different locations. So if you have not listened to part one yet, please go back and check it out. Today's uh episode is really gonna be building on top of what we covered last week. And last week, like I said, we talked about credentialing gaps, billing blind spots, denials, AR, um, and making sure that those are site specific so that your billing team is managing those. Again, your billing team should be pulling those site-specific reports, but these blind spots actually survive because of underlying data coming out of your second location, maybe inconsistent with your first. And also because no specific person in your practice may be accountable for what's happening at each location specifically. So today we're going to talk about closing both of those gaps. Really, this is all about systems. It's about structural things that you can fix this week if you have the right people in the seat and you have the right metrics to pull. All right, so system number three, again, we talked one and two in last week's episode. This is the third part of that. So the EHR and the billing disconnect across sites. Multiple location practices almost always have an inconsistency problem, right? And particularly at the front end process. And you may not quite find out about it until you're deep inside the billing workflow. And so you may have different front desk staff at different sites, different policies and procedures, or no policies and procedures, different habits. One site may be verifying eligibility in the morning of the appointment, calling people and doing this entire workflow, whereas the other site may be doing it differently or not at all. And this is especially true when it comes to collecting copays. Maybe you've got a really good staff member who's been doing this a long time. They get it, they know how to have difficult conversations. They're collecting those copies at one location, but the second location may have been trained, you know, once or twice. Maybe they have the written policy, but those staff may not be as comfortable with those conversations. And so you may have issues with collecting copays and patient balances at the other location. This isn't to say that that can't be corrected. Again, this is all about identifying the right data so that you understand how each of them are doing, where their blind spots are, and then being able to correct that. And so oftentimes what you can see is maybe site two is doing really well, site one maybe just hanging on. But when you roll up those metrics, those billing metrics across both sites, things start to get a little bit muddled in terms of really being able to call out the bad actors. And so your patient AR may be silently building at site two, not at site one, but when you roll those metrics together, it looks like both of them are doing okay. Right. So it makes your site, your site A maybe look a little bit worse, but it's it's such a rock star, it's not even called out significantly. And so your location at uh location A, right? That front desk has been maybe using your EHR for years. They know the system, they verify eligibility, they update insurance information, they confirm authorizations all without even being prompted, right? They don't need a checklist, they don't need a policy procedure. Maybe it's there, maybe it's not, but they're just running. Now, maybe your location B front desk was trained six months ago by location A. Maybe they have a have a manager who visits once a month or once a week, and they're obviously doing their best. Maybe it's uh, you know, those individuals are covering maybe certain multiple different uh areas within the office because it's still growing, it's still building, but maybe they're skipping the authorizations, or maybe they're skipping following up on patient eligibilities that fail. And so because those metrics are rolled in, you're not really able to see and pay attention to it. So the cost for this is something that most practices are not calculating. And what we see within our own sites when we take on multi-site locations ourselves is a practice could be doing 120 months at one location and maybe 20% of authorizations missing, which can be, you know, $20,000, $25,000 a month in claims into the billing queue with not the right data. And some of those claims get caught with scrubbing and some of them get denied, some of them get paid, and then some of them get recouped. So you're in this gray zone that nobody can really explain because again, those metrics are rolled up. So obviously you want to make sure that your front office in both locations is managed the same and that you have metrics to monitor the front desk at every site. You want to make sure that they're doing the same eligibility process, the same authorization checklists, really the same copay collections or patient collection scripts. And you want to make sure that they've been documented or that the staff have documented their training and that they're actually also audited at this other location, especially if you've got strong staff at one location, making sure that you are sharing site staff so that the really strong members from location A go over to location B on a schedule. And so that they are mentoring those individuals. They're checking up on those metrics. Your office manager is checking up on those metrics. And again, the roll-up may look really good, but again, you want to make sure that you're looking at those location-specific uh data metrics and that the staff on the smaller, newer location has the mentorship and the training consistently that maybe location A had early on, but now you've got two locations. So you got to make sure that that is shared. All right, the next system, system four, is the office manager. And this is something that we see as offices scale that, you know, really want to make sure that you have an accountability later layer holds a multi-location practice together. And that's where you can see, you know, maybe the office manager spends the majority of their time at location A, maybe sometimes at location B. And you really want to make sure that that individual has the same relationship, is setting the same culture, all at that location B because that level of staff may be newer, the processes may be newer, maybe those individuals came from location A, maybe they didn't. But you just really want to make sure that the office manager that you have really knows the process at the second location and is giving that location just as much of attention as they did to location A when it first started. And that's sometimes hard to do because now you have two locations. Maybe they're, you know, an hour or plus apart, but you've got to come up with a system so that the culture, the training, the problems, the metrics for location B are all visualized and understood so that they get to know the providers at that location. They know the payers that may be different. They catch those problems before they become billing issues is really, really key. Oftentimes, uh location B may have maybe a coordinator or a lead, somebody who was promoted, which is great to see. But again, they may be in learning mode still. And so that office manager or somebody who is coordinating care between both locations really needs to make sure, again, that you have that standardization. You want to make sure that you're looking at metrics at both sites and that those look similar on both locations. And you want to make sure that when you're looking at revenue per visit, you're comparing those between each location. And that may take, you know, six, 12 months for those two to come in line with each other, but it's just something that you want to make sure that you are paying attention to. And again, your office manager, your controller, whoever's managing the finances and the day-to-day operations just needs to have a good look at this. We see our most successful multi-location practices where they have, you know, maybe an office manager who's overseeing leads at every location. So that office manager can spend enough time at every place working on the training, working on the checklists, really making sure that the metrics at each location make sense and match, and that those individuals all feel part of that collective team, or that you have a sharing of staff during certain times, just so all the offices are known by all the staff. Obviously, if you've got an office manager who's not really paying attention to that secondary location, it is going to compound every single month. And the cost that practices miss when it comes to not having this aligned is again, if that location B office manager is missing those daily check items, maybe they're missing the eligibility, they're not collecting the patient payments the same, could be, you know, eight, $10,000 a month in billing delays or uncollected patient payments. So, really, really critical to close that gap. Again, this can be six figures in a large multi-location practice when it's not the same process or even the same person or the right person who can handle multiple locations. So obviously, you want to make sure that as the practice owner, you're hiring the right folks. They have the accountability structure, they know the importance of managing both locations and they have experience with that. Really, really important that you really pay attention to these newer locations as they're growing because you want to make sure those systems are set up correctly before the volume expands, because it gets harder to and harder to standardize things. We even see this ourselves. As you grow fast, you have to make sure that you're standardizing early on, almost even if you feel like it's not ready yet, because then it will be easier as you scale because you've already standardized things like your KPI reports, your denial rates, your days in AR, your eligibility process, your patient payment process, all of that just has to be really buttoned up again, almost before you're ready, because then when you grow, it becomes, you know, it's already there, right? It's already there. Patients, you've maybe added providers, and all of this uh stuff is all buttoned up. So obviously, when your front-end data is inconsistent across these sites and it rolls up into that larger uh data rollup, you may miss some of these inconsistencies. So, really important to have an office manager who's paying attention again to these site location metrics when it comes to eligibility, patient collections. Then on the billing side, of course, making sure your billing team is managing the AR and the denials by location and really paying attention to even those lower dollar claims, it may be less at a smaller location, but it can really impact revenue downstream, especially if you have those finances where you've got provider profit sharing at each of the locations separately. Those uh those billing issues or front-end collection issues can really contribute to a lower average revenue per visit at a smaller location or location B because those processes aren't in place from the get-go. So, really, really important to build these uh operational standards at every location and make sure that you have the team that can manage it. All right, so actions this week. First, make sure that you are auditing your front-end protocol consistency between both locations. Make sure that your billing manager is pulling those eligibility authorizations and especially denials of each of those so that you can close those gaps. You'll want to make sure that also that the office manager is spending time at both locations doing those working sessions, really making sure that the culture and the training at those other locations are rounded out. Next thing to ask your team to do is to actually do a site level office manager assessment at those other locations, right? And so if you have a COO or director of operations, make sure that they're evaluating those smaller locations so that they have the same level of standards that you held to location A. And this should not just be a gut check. This should actually be pulling data, doing rounding with the staff, looking at the denials at those locations so that you can make sure things are done appropriately. And again, most people, if they're doing something incorrect, it's not because they don't want to do it the correct way. It's either that they're overwhelmed, they don't have the right training, or maybe they just forgot, right? Because they're doing a couple of other things. And so that's why sometimes, you know, having staff around at both locations can really be helpful in making sure that they capture that culture from the first location and they're bringing it over to the second location. So the last thing I really recommend is that you have that weekly site level review. You're um having your director of operations, your office manager, having those standing 30 meeting, 30-minute meetings on the calendar between each of the site's uh leaders and making sure that those are captured. Sometimes a consolidated call just levels up really high-level issues, but you want to make sure that you're not forgetting those low-level things that can kind of stew. And then when they grow up, you're when volume, your AR can really uh compound both patient and insurance. So as always, if you liked this podcast and the last one, this is a two-part series, and you have never seen a site-specific KPI report for each of your locations, really important to do that audit. So we do have a audit checklist, um, which is a great framework to use. It's free. Head on over to the show notes and uh that link is down below. Obviously, if you are looking for a new billing team, head on over to our website and you can select the typewriter top right hand corner for free revenue audit, and we'll take a look at your metrics and see what's going on. All right. Thanks for sticking with us through both parts of this series. And hopefully this uh helps with managing those multi-site locations. Next week, we're gonna change direction a bit and we're gonna talk about revenue cycle functions that practice owners consistently underinvest in. And it's oftentimes a seat or a position in your office that you fill last that you don't really think about, or may even be underpaying now. And getting it is actually worth more bottom to your bottom line than potentially even adding another provider to your schedule. So subscribe now so you don't miss it, and we'll talk to you next time.