Is Your Practice Actually Profitable? The Conversation ABA Owners Avoid, with Camber's Nathan Lee —

Is Your Practice Actually Profitable? The Conversation ABA Owners Avoid, with Camber's Nathan Lee

Is your practice actually profitable? Not "is there money in the bank this week" — profitable, meaning sustainable, meaning you can pay your clinicians next year too. Most owners have never had that conversation with anyone. Nathan Lee and his team have it every week.

Nathan Lee is a co-founder of Camber, the revenue cycle company built to take owners off the critical path of their own billing. A former healthcare consultant at McKinsey, Nathan started Camber after watching family friends who ran clinics text people for payroll loans while payers sat on their money. Today Camber runs billing operations for ABA practices across 45 states, with a team of more than a hundred in New York City, backing from Andreessen Horowitz and Y Combinator, and predictive models trained on over 2.5 billion dollars in real claims data that flag a denial before the claim is ever submitted.

This is the conversation about the difference between hoping you get paid and knowing.

Here is what we get into:

• Why owners who never worried about cash suddenly are: medical record requests, eligibility denials, and payer tightening across the entire portfolio
• The spotlight on ABA: what rising payer scrutiny means for your denial rate, and why it is not out of your control
• The hard conversations: is this practice actually profitable, and why profitable means sustainable, which means paying your clinicians
• What automated billing actually looks like day to day, and why the fix has to start with the feedback loop, not the appeal
• The collection-rate truth: 97 percent in eighteen months is not the same as 95 percent in thirty days
• From uncertainty to security: what the first ninety days feel like on a dashboard
• The pending-authorization session you deliver anyway: turning a gamble into a math problem you can run with a family in mind
• Your homework before Boston: one litmus-test question and the two numbers that answer it

Resources:

• Camber: camber.health
• Nathan Lee on LinkedIn: linkedin.com/in/nathanlee-145

Nathan's session, From Reactive to Predictable: Designing a Business That Scales Without Burning Out Your Team, runs at the ABA C.A.R.E.S. Summit, August 4 through 7 at the Boston Marriott Long Wharf, and stays on demand all year for registrants. The Camber booth is right at registration, straight across from ours. Before you walk up, sit with one question: do you feel secure about the financial health of your organization? If your honest answer is "maybe," this episode is your prep work.

Register: https://behaviorlive.com/conferences/abacares2026/registration

Go take care of your people. I'll see you in Boston, or on the other side of the livestream.

Transcript

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SPEAKER_00 0:00

Holly Beth. Welcome back to Inside ABA Cares, the behind the scenes action where we set the stage for what we're going to talk about in the full conference this August and who you'll meet. I have been in the field for about 21 years. I met the same clinic owners over hundreds of times with different names. She hasn't taken a vacation in five years, not because she doesn't want one, but because she steps away from her desk not knowing if payroll is going to clear. She's in handwriting checks by hand. The entire revenue cycle of her autism therapy practice, every rendered service, every dollar in the bank runs through her physical presence at a desk. And right now, with Medicaid rate pressures, private equity rolling through the field, and the workforce stretched thin, she's not an outlier. She's in the middle of a bell curve. Nathan Lee is the co-founder of Canberra. He spent years in healthcare as a consultant watching operators try to fix broken revenue cycles from the inside and launched Canber in late 2020 to build what wasn't existing in the space. And today, Canber runs billing operations for ABA practices across 45 states. That means Nate sees patterns in ABA finances that most of us don't get clarity on or get to see. And we're going to pull on that thread today. Heads up, we're going to give you some homework at the end of this episode. Two or three questions that you should bring or start to think about your own numbers before the conference in August. So grab your phone, grab a pen, and get ready to jot down some good notes with Nate. So Nate, welcome to the podcast.

SPEAKER_01 1:37

Thank you so much for having me. And it's uh when you said that we started the company in 2020, obviously out of COVID, but also six years doing this and feeling really thankful that being able to build this expertise over the last six years to now be in such a pivotal time, I think, for the industry, where, like you said, more and more challenges on the Medicaid side. There are cuts that are happening, there are authorization utilization type of requirements, shrinking. There's a lot more pressures now and also just the way that insurance payers are looking at ABA today, very different than five years ago. And really excited today to have this conversation and be able to provide some clarity and some behind-the-scenes type of insights on how we can navigate this type of change as the industry's been changing. And the great news is it doesn't have to be a mystery. And I think right now there's a lot of feeling of payers are coming out just with a press release or a new thing. And there's a bit of feeling, at least with the clinic owners that I talk to sometimes, of it being out of their control when in reality, the technology that we have today, it can be more in owner's control than it ever has been in the past. And I'm excited to talk about some of that today and also just catch up because it's always great to speak with you.

SPEAKER_00 2:49

Always great to speak with you. And I always walk away with learning something new, even though I've been in the space for as long as I have, because your team is so intentional and how it looks at not only with the problems that you're trying to solve, but what the industry as a whole is trying to solve. And so I'm really excited to sit down and hear what conversations you're having with some of the owners that you're sitting across from and what they're seeing consistently and what's happening inside their own businesses that that is giving some of that anxiety. What do you see bubbling up the most when you're having these conversations or people are coming to you looking for solutions?

SPEAKER_01 3:26

One of the most common patterns is the clinic owners that used to expect money to come in are feeling the pressures for the first time of that money not coming. It's some of the dynamics that we saw in the beginning days earlier. When we were starting this company, uh, one of the great motivations for it were talking with family friends that ran their own clinics locally where they had challenges just payers not dispersing the cash before the payroll period and it catches them by surprise. And then they have to text a family friend to get a few thousand dollars here and there to make payroll. That has always happened, but the frequency in which that's bubbling up today with owners that have not had that be a challenge in the past is increasing. And these days it's things like denial for more medical records for a good example, where payers are systematically, and we see the trend lines across our entire portfolio of data of med rec requests going up very, very quickly, eligibility type of denials going up quickly, authorization-related denials, things like that, where payer policies and tightening of the way that they're enforcing them is just making it more challenging for these owners. One of the patterns I'm seeing what's bubbling up are owners that in previous years would have said, hey, this is going totally fine. I don't really think about it, or for the first time saying, like, hey, this isn't working the way I expect it to, what's going on, and getting that education for the first time. So that's definitely one dynamic. The other dynamic, uh, you mentioned at the top, kind of the dynamics of private equity and finance and things like that entering the space. Of course, with uh things like uh clinician and payroll and the wages and rates and things like that, just making the margins of running sustainable practice more challenging. With both those things, practice owners are at a very high level realizing that the way that they've done and run their practice in the past may not be the way that they need to run their practice going to the future. And that awareness of, uh, I think it might be time to change is one theme that I'm hearing a lot these days.

SPEAKER_00 5:14

Aaron Powell You mentioned some things that might have changed, like different requirements coming from payers. But how much is the ability for payers to use AI to find some of the stuff that they used to slide by, in your opinion? What is creating this change?

SPEAKER_01 5:30

The thing that's creating the change most is there's just more of a spotlight on the field than there's ever been before. As a founder of an organization that has been blessed to have a pretty robust network of great advisors and folks that have had incredible experience in this space. For example, like Julie Klapstein is one of our advisors. She was a founder and CEO of Invalidity for multiple decades and put together one of the first clearing houses connecting providers and payers together in the 2000s. We were talking about how the way that payers look at things like dispersing dollars, for example. A lot of it's where the money goes, and it's how much money is going where and how much attention is there from leadership. And what we're finding is for folks who can read about in like the Wall Street Journal, the New York Times, these different articles about ABA, and the attention and spotlight that is on ABA as a field from the payer side is higher than it's ever been before. So actually, yes, there are new tools that payers are using, including AI. And I have some anecdotes there of how we see that happening on our side. Definitely true. But what's causing it top down is just more focus on higher spent. And there are certain states we've seen in our data where the rate of spend is just going up incredibly quickly. Also, a lot due to the diagnosis rate going up over the last two decades and great work on network adequacy, which is also great. And as a result, there's just more scrutiny. And the way that payers are now trying to understand, hey, what do I want to pay and what do I not want to pay? It's a bit of a new era of what they're willing to do to, for example, deny for medical record requests. Where in the past might have just gone by. Now they're saying, well, I want to see more records. I'm going to do more PPRs. I'm going to do more audits, things like that. And that's the trend across the board on the payer side that's impacting providers.

SPEAKER_00 7:07

I'd imagine that is very hard to distinguish good ABA and bad ABA and what should be covered medically because there's so much coming in and it's a new field. Is that part of where the scrutiny is coming from? Do we need to do a better job of helping them understand the field and define what quality is? Or in your opinion, how can we help?

SPEAKER_01 7:28

Yeah, definitely the case. I think for any kind of payer, the one thing that they're looking at is the needs of the lives that they cover, as well as what good treatment uh looks like for those lives that they cover. Uh there's been a lot of work in the past about things like quality of care, value-based care, things like that. The interesting thing that's changing the dynamic is the public scrutiny, which has had a lot of voicing in the zeitgeist of what ABA is and its effectiveness. Just simply that just means that payers have more focus on it. Where in the past, ABA might have been a fraction of total spent for an insurance payer. And that's increasing. You can even just hear public earning reports for different payers where they're talking about behavioral health spent as a whole, which is not just ABA. It includes things like substance abuse and nutrition, all these other types of things as well, which in my mind is actually a great sign of the way that American healthcare is moving towards things like better therapy and more preventative and proactive type of approaches. And insurance payers are now trying to compensate from like a catch-up perspective of how much scrutiny they're putting on, which then impacts denial rates. It all comes top down, the scrutiny, what's in the site, guys, which then leads to tightening guidelines and the willingness to increase denial rates or increase appeals or ask for more medical records.

SPEAKER_00 8:42

Makes sense. And one of your clients, Alexis at Wild Sun, she said that your business card on her desk sat there for a year before she picked up the phone. What's going on for business owners with that hesitation about understanding how they even start the first conversation or even understanding what Canber does and how it helps?

SPEAKER_01 9:02

A lot of the owners that I talk to, like Alexis and Dan, who are awesome, by the way, is wanting to have the right trust and control over the health of their practice. Because it's a serious thing. What we do at Canber is we make sure that you get paid by insurance as easily as tapping a credit card, which I think the first reaction when I talk to owners about that is, yeah, sure, like you can say that. But like in reality, can you actually do it? For Dan Alexis, it was a year later. We also had more experience, which has been really great. And the other part is it's harder and harder to do it yourself. The amount of expertise that you need to do it well, the fact that the volume is going up with the denials you need to appeal, the requirements that payers have that are getting more complex, the unwillingness to backdate an authorization or a credential for a BCBA. These types of things are making it harder and harder. There's this balancing act between, as an owner, can I and should I do it myself and try to exert the control over the financial health of my practice? And where do I need an expert to help? And an expert that I really trust to do right by me and to make sure that my practice is sustained and that I can deliver the great care with the clinicians that I have my payroll. That calculus is changing because of how much harder it's getting to get paid by insurance over time with these different dynamics.

SPEAKER_00 10:13

Yeah, it's definitely hard to work in a vacuum, but you hit the nail on the head when you mentioned trust, because I have seen it go the opposite way, where you're entrusting somebody to do the billing and then you're about a year in and realize they were double billing or whatever the case is, it happens and it ruins relationships. If I were the business owner, what would you advise me to do when thinking about my tech stack or who I let into my inner circle and my company?

SPEAKER_01 10:38

Yeah. The first piece of advice I'd have is if you have other owners in your network that are succeeding that you trust, talk with them, which I think already happens. That's one of the great pieces about our industry. I think our people in the right circles, especially if you attend something like an ABA care, is you have owners that are so deeply invested in helping the industry and helping each other like move forward. And part of that trust is to go talk with someone you trust to say, hey, what's working for you? And one of the things that I like doing best when an owner asks me, like, hey, can you do this thing? I'm like, yeah. So let me explain how that works. But also, hey, you should go talk with Alexis uh to get her take on what that experience has been. Because I think there's no better way to earn that trust and say, like, hey, this is not just me telling you as a founder of this company, but this is someone that we've served for many years that can uh say that we do right by them. That's one. The other one is looking at the track record of how many years have they been doing this. I think one of the really cool things about what we've been able to build at Canber is we now have six years of incredibly robust data that informs the way that our models predict whether or not something's gonna get paid or denied. And that alone, from a track record to outcomes, to achieve those outcomes perspective, speaks for itself in a way that I'm really proud of that we built a company that can do that and use that expertise to positively impact clinics. Our duty that we can do for clinics that want to um do right by their patient families. Folks that have been doing this for longer, folks that have gone through the ups and downs and the battle scars and the learning. As a company, we've had plenty of learnings too. I'm happy to talk about that and trust because I think it goes hand in hand. For those that are able to, with all the years that they've been developing, consistently prove that they do right by the customers that they serve and are continuing to invest uh in that type of quality.

SPEAKER_00 12:15

Yeah. And so what has some of the owners mentioned to you that they see in the first 90 days? Are they gonna feel difference in the day-to-day? Or it's all seems magical, like we'll just submit and we get paid. So, like, what does it actually look like?

SPEAKER_01 12:30

Yeah. Here's how it actually looks someone like Dan Alexis of Wild Sun, they'll have their own clinical tool, they'll have their own practice management system. And really what we're doing is we're taking the work that used to be done by a human biller or a human collector or someone that will call an insurance payer and submit claims in the payer portal or in their system by hand. And we are automating that entire process. How? We are inside the practice management system. We take the data on the session itself, the provider on that session, the authorization, the credentialing, all the different data that we need, put it into insurance claim automatically through our infrastructure, and then run it through predictive models that basically tell us in advance will this pay or not? If it will get paid, we submit it automatically overnight. And then we do all the follow-ups with claim status checks, with uh calls to the insurance payer, looking at the payer portals, all that kind of stuff, and following up on it until it gets paid. If we know it won't get paid, we flag it immediately to say, hey, this is missing authorization, or hey, this BCBA that's on this claim, we know that they're not credentialed with Blue Cross Blue Shield. And so we know that that's going to get denied. And by doing that in a way that doesn't require a human to do that by hand, the speed and the quality at which that gets done is just way higher than a biller who also might be you as a clinic owner, where you're doing this the nights and weekends, and you have to have all this knowledge in your head. It just happens automatically through the technology we built. And we're really grateful and blessed to have dozens of engineers sitting here in New York City with a team that's now uh growing above 100 to do this work and make this build uh possible. And doing that for many years. At this point, we're processing well over a billion dollars worth of insurance claims every year. And so that ability to do that at scale with local clinics all the way to large national clinics has been a huge part of why we've been able to have the outcomes that we can for our owners.

SPEAKER_00 14:20

I'm curious, for a couple of years now, you have brought in your engineers to speak to people who are in the industry doing different positions and help them immerse themselves in ABA. Has that made a difference?

SPEAKER_01 14:32

Huge difference. Huge difference. When we onboard our own people to Canberra for the first time and describe the impact that we have, I think one of the most important things we've been able to do is show them on the ground or even go to a clinic with them and say, like, hey, the kiddo that's just on the screen in a database that we're submitting insurance claim for through this automated pipeline, here they are in the room. That's them. And they're working one-on-one with this RBT, with this background, who's also on the CMS 1500. And by putting together the pure data technology type of building with the humanity of the impact that we're having for real families, I think really drives the stakes that we feel to do this well and do right by our people and do right by our owners and the families that they serve. And so we have so many instances and stories like when change healthcare went down, engineers were working nights and weekends to get it back online because we knew that the implication of not doing this would mean clinics would not get paid, and in some cases, like millions of dollars, that they needed to make payroll so that clinicians could stay on board to serve those families. The stakes of that were very clear to everyone in the organization. They're really proud of the work that we did, not because me as a founder said anything to our engineers. They wanted to do it. They really, really cared to make this happen. And I remember how many months later, the end of that year, I was catching up with Brooke Madden at Ginger Lee Therapy in Nevada. And she was telling me about like how during the change healthcare hack, all these other clinic owners were having trouble getting paid. And she just mentioned offhand, I didn't really notice. And then she kept talking. And it was like one of those moments that I think about a lot and we're really proud of is for an owner like Brooke, who's serving these families locally in Las Vegas, she didn't have to think about that. The change healthcare hack was one of the biggest cyber attacks in US healthcare history since the year 2000. And it was as if Visa or MasterCard went down. And to then have an owner say, like, I didn't really notice that. That's the type of impact that we want to have that when we onboard our engineers and we tell them like why we do the work and why it matters really resonates with us and our DNA.

SPEAKER_00 16:25

I like it. I picture you guys are like a generator. So if the power goes out, you're still running. You still got it. Um you're always going. I like that. Give me another example of how that could impact the owners.

SPEAKER_01 16:37

Yeah. When an owner is coming on board for the first time, they're usually coming from a place of uncertainty. And the feeling that they should have with Canber is security. When they look at a dashboard in their first 60, 90 days, they're not guessing how much money is hitting my bank account versus how much money should be hitting my bank account. They're saying, well, actually, before in the first 30 days, you were collecting 50% of your dollars. Maybe it was as high as 80%. But now in the first 30 days, you're collecting 95%, 97%, 98%. Or, okay, no, you're only collecting 80%. Well, 12% of that is because we need this authorization that's missing. Or 8% is because, hey, that clinician needs to be credentialed with BCBS. And that security and that clarity is what they should feel. So when we create and build these dashboards with our account managers, when they have these conversations with owners, they're relieved a lot of times. It's a feeling of I do finally see what I should be seeing and understanding its impact on me and my organization to say, yes, I do have payroll in next week. And I do know that based on the historical data, that for this pair, we're expecting 93% of that to be paid by next Tuesday. And for this other pair, it's probably gonna be around 96%. For that pair, maybe 85. And by adding that up, payroll should be just fine. And then eventually, they shouldn't think about it too much. What they should be thinking about is what do I want to do with the financial security that I have today? Where do I want to invest? Quick story here. I saw a Slack thread from one of our account managers that was doing great work with an owner, and this was in January. And so that owner was doing taxes with their accountant. And the accountant had been serving that clinic owner for six, seven, eight years and called the owner asking, Hey, I was doing your taxes this year, and I noticed $83,000 more dollars is in the bank account than any other previous year that we were expecting. Why? And the owner just said, we're using Canber now. And then the accountant was like, Well, that's great. Do we want to invest in upgrading our supplies? Do we want to get new equipment for the sensory room? Do we want to upgrade the IT? Because, hey, if we should actually invest a little more and take a little capex off and we'll help with taxes and all that kind of stuff. And it was a new conversation that they haven't had in more than five years. And I think that's what the exciting thing is: like, okay, in the first three days, security, you feel the clarity of the impact it's having on your clinic. And then as you get to a steady state, the conversation turns into where do we want to invest? Who do we want to hire? Do we want to open up a new clinic? Dan and Alexis talking with them over the last few years, they've opened up some work on nonprofit schooling. That's really where the conversation should go and the possibility.

SPEAKER_00 19:06

Yeah, yeah. And at what point do you feel like it gets steady where it doesn't fluctuate very much?

SPEAKER_01 19:13

Great question. It should get steady within the first 90 days, if not sooner. But it also depends on the clinic. One thing that um I'm also really passionate about as a founder is as we go in and understand what the clinic in the business looks like, we will give the most honest assessment of what we think that this is gonna look like. So, for example, if we know that there's a particular payer that won't name names, is doing many more audits and we know that. Well, what we can do is actually tell them, hey, we're probably expecting that some kind of audit's gonna come up in the next quarter. Do you feel prepared? And so will that feel stable or steady when that comes in the next two or three months? Maybe not. But there's a sense of security of, hey, Camber's my partner that is invested in understanding that with me and is sharp and can help me and prepare for something like that. It is case by case dependent when it's an easy case very quickly. The reason why a lot of these owners are coming back and having conversations with a kind of like Alexis keeping the business card on the desk for a year is as things are getting more challenging to get reimbursed by insurance, folks are looking to us to be the subject matter expert and their partner to be able to prepare for the world that's coming in some cases already here.

SPEAKER_00 20:19

I have some clients that I work with and they come out of a meeting and we're talking about what they can invest in in terms of training or onboarding, or you mentioned putting it back into the company, but they say, well, one day, like we're waiting for $82,000, you know, dollars and it hasn't been paid yet by X Company. Is that something that if an organization comes to you and they're already not being paid a certain amount, do you assist with that too, or is it only going forward?

SPEAKER_01 20:47

It's only going forward because the way our technology works is to work with the data end to end. A lot of what we build is technical infrastructure. And the learning that we can do to most successfully process and automate all the claims, it matters that it starts from the beginning and goes forward. We do though do analysis on everything that's but before this point, because that information helps us inform how to tune and how to adjust the way their infrastructure works with that specific clinic, that specific payer set, that specific set of codes and modifiers, that fee schedule, things like that. I think the clarity that folks get when that process is in place is they don't have to wait or guess for when that $82,000 is coming. They can start preparing for it. That's a future state that we help our partners get to by working with us.

SPEAKER_00 21:31

What do you wish your partners knew before they came to you? So when they're just opening up their clinic or they're a couple of years in, what kind of information do you wish that they had?

SPEAKER_01 21:41

Two things come to mind. One is what uh I would love for them to know about us. And the other one is what I would love for them to know about their own operations as they're coming on board. For us, it's how much we deeply care about partnership with them and their success. And the willingness that we want to have the type of conversations that we need to. To get to that feature. And sometimes those conversations are challenging. One quick story is uh we do these uh net promoter score surveys, which for those that aren't familiar, it's pretty simple. Just would you recommend us on a scale for one to 10? And just some quick details on why. And we got one from a clinic owner that was very high, and he put a really interesting comment, which was the name of our account manager had the hard conversations with me that I don't think I could have had on my own. And I will forever be thankful for having those conversations. And those conversations were around things like pretty hard topics, around things like, hey, is this practice profitable? And profitable means sustainable, which means paying your clinicians, which means taking care of your families. And the answer at the start of that was actually no. And we helped do education to say, like, how do we get to a place that is sustainable where you can pay your clinicians and maybe pay them more and take on those clients? Where are you because you're taking on clients where you don't have in network stats with those reimbursements? You're not getting paid out. So actually you're losing a lot of money that then impacts your ability to make payroll. Things like that. One thing I wish folks knew as they come to us is the deep care that we have for doing right bar clinic owners and I'm willing to then have the type of conversations that we have to make this successful together. What I wish that they would also know about themselves too is what type of operational rigor have they put in as they're starting to work with us? Because a lot of that success, too, is the clinical quality of care and how much they care about their staff and training them well and educating their families and doing great work almost always is something that is very top of mind for these owners. The other piece that should be top of mind is how's the operational excellence of running this clinic? How well do we get the right information when they come in the door? Do we get the insurance card? Are we doing the right intake process? How is scheduling working? Are my clinicians signing off their notes? Does a parent know what the schedule looks like? Are they accounting for the holidays and vacations? Things like that, because all of that flows downstream. And for us to be good partners, working together with a really tight operation, I think is a huge part of success.

SPEAKER_00 23:51

So when you're looking at some people that come to you, sometimes they're not ready to be a client yet. Do you give them information on what they need to get ready, or do you take anybody and just help them fix it?

SPEAKER_01 24:04

Both. Absolutely. In some cases, when they're not ready, it's also because they may not be at a size where it makes sense to work with us that's best at scale. For example, like a solo owner operator that's working on a Google Calendar with their own uh maybe half dozen different client families. That could be one reason that why they're not ready. But for folks that aren't ready because of setting up their operation or that sort of thing, that is what we feel incredibly passionate about helping owners through. Because you've heard me say this before, Holly, but uh we very rarely ever talk with a clinic owner that said that they wanted to start their practice because they loved knowing how to bill insurance or do admin or all these other things. Rarely ever happens. And so we want to, and our mission is to give those owners the time that they want to take for their people and their clinicians and the care. We'll take care of the rest. And that means co-building this together, even when they're not ready when we start.

SPEAKER_00 24:54

When you are looking at it, what KPIs are most impactful for the practices that you serve that tell the true health and the true story of the company?

SPEAKER_01 25:03

From a revenue cycle perspective, which is where we really focus, one of the top KPIs that we look at is collection rate within the first 30 days, collection rate within the first 60 days, because it represents how quickly you're able to make the cash that ultimately you need to use for payroll and rent and all these other things and investments. One thing we teach a lot of clinic owners for the first time is hey, the person you're billing may achieve 97% collection rate, but it's gonna take 12 or 18 months. And so really what we want to do is say, let's get that 95, 96, 97% in the first 30 days. Let's get it on the first submission, right? And that's where a lot of clinic owners struggle too, is when they only get paid maybe 80% in the first 30 days, they're then working nights and weekends to try to get the rest, or they just never do, which is pretty common as well. And you can read the reports out there of insurance denials and the rate at which owners actually even decide to appeal them, it's low. It's way lower than 50%. And so even that kind of burden, it's very challenging. So the KPI of what's your collection rate in the first 30 days, first 30, 60 days, very important. And that's really where technology can do a ton of heavy lifting.

SPEAKER_00 26:07

When somebody goes from 70 to 95% in a couple months and you see that change, where does the recovered revenue usually come from?

SPEAKER_01 26:16

A lot of it's denials. A lot of it is the feedback loop that's missing from the denials that are happening and change up front. There's a feedback loop that's broken. There are people that are not talking, there's speed, there's capacity that's not addressing, there's a denial for a lack of authorization, but upstream, no one knows about this. And so they keep putting in the same system or sessions or things like that without having that authorization, which leads to more denial. So it's that vicious cycle that happens without a feedback loop that often leads to money not getting paid at the end of the day. And so a lot of the technology that we use is to complete that feedback loop automatically. Hey, you should know before anything else happens that if we submit this as is, it will not get paid. And what that does is it helps give owners the clarity they need to change things up front to get that credential, get that authorization, whatever it is, to get paid from 70 to 95% in just two months. And the cool thing too is when we do onboardings now, we've done this for enough years that we run that analysis and dry run process before a single claim is ever submitted. Because the way that our models can predict this, we don't even have to submit claims anymore. We can just tell. And so all that work, we look at the historical claims, we start ingesting, do that dry run, and we're able to just project on the first run, like, hey, it would be paid 70%, do these things, we'll be paid 95%. Let's go do those things.

SPEAKER_00 27:31

Can you name one or two things that people can take control of and stop doing? I've been more on the clinical side. And the one thing that comes to mind is when you're in a session and you see the authorization has not been approved, but you can bypass it and say, that's okay, we're gonna do the session anyway. Is that one of the things that we're talking about here?

SPEAKER_01 27:51

Great question. Um, this is a classic one for ABA, is delivering a session without authorization yet in place. A lot of folks might be familiar if you're on the clinical side, maybe you have a little drop-down box and it says like pending authorization or something like that or normal authorization. You're like, well, I guess I'll use that one and keep going. That's a great example of the clarity that you need as an owner to say, is that okay or not? And the answer is it depends. Some payers will say, Oh, we will backdate your authorization once it's approved and that's okay. Other payers will not. And no, you're never gonna get paid for that. And that is often the case, especially we talked in the beginning about the different dynamics of these guidelines tiny up over time by payers as there's been more scrutiny. That is one of the classic areas that we're seeing pair guidelines get more stringent on. Say, hey, we used to backdate these offs, we won't do it anymore. And so pending authorization, yeah, you're not gonna get paid on that. But clarity also means judgment calls and decisions to say, actually, that's okay. Because I understand as an owner that the really important thing for this family is that they start getting care today. And we understand that there might be a delay for the authorization and we might miss a week to actually collect from insurance for that first week. But because I understand through camber dashboard reporting, things like that, that the impact of that is manageable and it's worth it to get this family in the door to start delivering care and make an impact on this family. That is why I think clarity is so important. And we're helping owners understand how that will impact their practice and ultimately the sustainability of it and their people as we go through on the phone.

SPEAKER_00 29:15

Let me see if I understand this right. So with the dashboard, the owner can manipulate some things to see like what the risk to benefit could be to see if they can take that risk to help more families. Is that something that they could do?

SPEAKER_01 29:29

Yes, we do the math with them. And that math says something like, okay, for this particular patient family, we know that they have an insurance plan that does not backdate their authorizations. We understand this is going to be a denial rate. And that's okay, because if we then project out how we're planning on serving this family over the next three months, six month, eight month period based on the plan of care, we understand that it'll have this impact on our organization. And so the cool thing about the dashboards is you can take that high-level view and drill down all the way down to the patient family level, uh to the provider level, to the insurance level to do that. When we work with our owners and partner with them, that's a lot of the work that we do to help educate them on how that works and how the math actually shakes out.

SPEAKER_00 30:11

Yeah. That's so helpful to be able to have a partner that's able to do that so that you can take the right risks in order to help others without risking the closure of doors, which is happening. So that's that's great. In the field of ABA, work in this weird growing moment, PE consolidation, Medicaid, rate pressure, workforce shortages that we all know all hitting at once. What are you seeing on the financial side that others should be paying attention to that you would say over the next 18 months or so?

SPEAKER_01 30:43

Yeah. The first thing that I always suggest when I talk with clinic owners is doing an incredibly robust internal audit and review of their operational financial rigor. We were talking a little bit about the different dynamics happening with increased rate of audits, medical record requests, things like that. That will likely continue to be the trend. That's what we're seeing. The data for denial type trends or auditing type trends is increasing over time. So the very first suggestion I can give is to say, now is a great time, if you haven't already, to really take a high scrutiny view of your own practice. What would happen if an audit came along? What would happen if we went through the medical necessity? How can I use training and tools and things like that to really have operational excellence of the practice that I'm running, especially when it goes to what payers are looking for is quality and satisfied members and being able to direct and steer patient families to high quality practices is increasingly where this is going. It has been for the last few years. So that's the first one I'm seeing. I think for the financial side, that financial rigor and scrutiny too is what is that we call it margin profile, which is just a way of saying when I deliver my service and I'm running my practice, am I making a profit? And making a profit, I think sometimes gets construed as like in it for the money, which is absolutely not what I mean by that. What it means is what happens if there's a 10% Medicaid rate cut? What will happen to my ability to make payroll? How much money am I making today? What's that percentage? What will be the impact if this happens? If I have uh the need to increase the salaries I'm giving to my BCBAs, whatever it is. And I think determining that and figuring out not flying by just what's in the bank account week over week, but actually doing that review, I think is super helpful. And we've worked with partners as well through uh the help that they give and consult with their owners, like ABA business coach uh that Molly runs over there, for example, to help actually go through and put together that financial picture. Ethan at flight chain is also a great one to mention there uh to help give that clarity, I think is super important.

SPEAKER_00 32:41

Yeah, absolutely. I'm glad that you mentioned just because you're looking at financials, does that mean that you are money hungry or have a bad practice? And so how would you advise somebody to talk about financials or uh what are some of the the green flags in knowing that somebody is not doing something wrong? Like I'm sure you've seen some of the articles. I'm not gonna point fingers, but putting people and clients and staff in harm's way just to squeeze out like one more dollar.

SPEAKER_01 33:12

Yeah. I think the first thing comes to is not how they talk about the financials, but how they talk about their care that they're delivering to their families. I think it's very obvious when we're having so many conversations with practice owners, their motivations of like why they started or who they're working with. There, there's also great stories of folks that I talk to on the finance side that say, hey, the first thing we do is we want to find an incredible clinical director to make their mission possible and do that partnership. And for those that have that type of mission and that type of motivation, it's one of the first things that they say, which is really cool. And for those that are owner operators doing it as well, you can tell the passion that they have for the clients that they serve. That is one of the first indicators. I think the second one is as they talk about things like uh financials and financial health, it's really in service of what? And a lot of it is in service of sustainability. A lot of it's in service of making sure that we can make the right investments in our people, making sure that we can demonstrate the right quality of care. Those are the types of things that we're looking for with partners because that's very important to us. And for especially the ones that are going to, we think, be the successful providers of the future, that is going to be hand in hand with what families are desiring for a great kid for their own kiddos. And also what payers are looking for ultimately as they try to understand what good quality looks like.

SPEAKER_00 34:26

Yeah, absolutely. Bringing the value and being able to describe that more is so important. So we've spoken before about Grayson and how they grew 60% in two years running ABA alongside OT, PT, speech, and neuropsych. What does an owner need to have in place before they add that second service line, in your opinion, that you've seen be successful?

SPEAKER_01 34:49

I think first is the things that I can't and certainly won't speak to, which is the clinical quality in the context of the families that they serve. I think that is a huge one. And I think it's the first thing that comes to my mind. From a financial and operational perspective, I think it's understanding, like we talked about before, the operational and financial rigor and health of the organization to make that sustainable in practice and uh what happens when you start putting that together. And for those that are considering adding a second service line, depending on your background, understanding fee skittle rates for different CPT and charge codes, denial rates for those different service lines, uh that works by payer. I think there's a lot of different pieces that you can put together to create that model. And for those that are looking at that type of growth and expansion, I think that subject matter expertise is really what's required. One thing that's really cool about the way that we partner with our owners is we help walk them through that with organizations, both large and small, as they consider expansion, growth, maybe entering a new state for the first time. What do they need to understand? Adding that new service line or things like that, having the clarity of how the financial and operational model will work together before they make that decision is super important.

SPEAKER_00 35:55

Something that I've personally enjoyed witnessing is the coming together of you don't have to work alone and in a vacuum, having partners is so important. Um, and that's what keeps resonating back to me as you answer this. And so I'm wondering if you could give our listeners some homework who might not know they need to be asking themselves. You mentioned doing some sort of internal audit, but maybe they don't even know what to look at. What is some recommendations that you have?

SPEAKER_01 36:23

At the very highest level, I think there's a litmus test question that you can start with, which is just simply do you feel secure with the financial health of your organization? Do you feel secure? And it's actually a feeling. And I like starting there because even if you have no experience as a financial operator or an administrator or anything like that, you can simply just ask, do I feel secure? And if the answer is maybe or I don't know, I think that's the first thing to consider is hey, maybe I should go look deeper. And I think starting there is super important because the more that you can find the simple limits test, that might lead to hard things, but it's simple nonetheless, I think is a great place to start. I think if you feel great about it, that's great. And then the next question would be why? Why do you feel great about your financial health? Well, if it's just, well, I don't really think about it, my bank account's fine. I think that leads to the next question, which is a little more homework. It could be things like, do you know what your collection rate is in the first 30 days? Do you know what your collection rate is in the first 60 days, first 180 days? How does that compare to your payroll spend, your rent, your things like that? Starting with the really simple question is the first piece of homework. And then moving to, okay, do or you don't feel secure in your financial health, go find those two numbers. And if you can't find those two numbers, this is a great indicator to say maybe my homework is do I need to consider finding a partner that is in my court that has that kind of expertise with many years of background. We'll love to talk with folks at CARES, whether you feel like you have that confidence or you don't, and share kind of learnings with each other. I think it's really cool, like you said, of how folks are coming together in that village model, both on the care side and making each other sustainable and successful.

SPEAKER_00 37:54

Nate, thank you so much. I think the advice of even if it's on the plane, like just have that gut check when nobody else is around, when you're not distracted, even do that gut check on the way to cares and then have the conversation. Nate is going to be talking about from reactive to predictable, designing a business that scales without burning out your team. And that's gonna be August 4th through the 7th. It'll also be on demand for an entire year for anybody who's attending either on-site or virtually. And so, Canberra, you're also gonna have a booth right when you walk in to registration. So we'll be right across from you handing out some goodies. Stop by and talk to the Canber team. They're team players, they are partners and really intentional. And you'll know it. These are the people that when you talk to, they're not looking through you, if you know what I mean. They're talking to you. So don't be afraid just to come up and and have the conversation. We'll see you in Boston or we'll see you on the other side of the live stream. So thanks for joining.

SPEAKER_01 38:51

Thank you so much, Polly. And uh, we'll see you in Boston.