CASE STUDY: Improving Revenue Integrity for a Tribal Health Clinic Background

April 16, 2025

Industry: Tribal Healthcare
Services Provided: Revenue Cycle Management

Overview

A Tribal health clinic serving approximately 3,500 community members in the Western United States began experiencing revenue shortfalls despite rising patient visits. The clinic, offering integrated primary care and behavioral health services, is partially funded by Indian Health Service (IHS) and Medicaid reimbursements.

With increasing denial rates, delayed reimbursements, and inefficiencies affecting both revenue and patient care, clinic leadership engaged John Lynch & Associates to perform a comprehensive revenue cycle assessment and implement targeted solutions.

Objectives:

• Reduce claim denial rates and improve billing accuracy.
• Identify and eliminate sources of revenue leakage.
• Ensure compliance with IHS, Medicaid, and Tribal billing regulations.
• Strengthen staff training and reduce turnover-related knowledge gaps.
• Accelerate provider credentialing to avoid lost revenue.

Challenges:

• High Denial Rates (23%) due to coding errors, inadequate documentation, and inconsistent modifier use.
• Revenue Leakage from unbilled encounters and workflow gaps.
• Compliance Gaps stemming from outdated policies and lack of internal audits.
• Staff Turnover that led to undertrained billing personnel and process inconsistencies.
• Credentialing Delays that prevented timely billing for services rendered.

Solutions Implemented:

1. Comprehensive Revenue Cycle Review:
John Lynch & Associates conducted a full revenue integrity audit, analyzing workflows, claim data, and team structures. We delivered a detailed gap analysis aligned with Tribal and federal healthcare standards.

2. Billing & Coding Optimization:
Certified coders collaborated with clinic staff to:

• Create custom coding guides tailored to Tribal and behavioral health services.
• Standardize documentation practices and modifier usage.
• Deploy real-time documentation checklists to improve provider accuracy.

3. Compliance Program Development:
A culturally respectful compliance framework was implemented, incorporating:

• Requirements from IHS, state Medicaid, and Tribal governance.
• Quarterly internal audits and staff-wide training sessions.

4. Workflow Improvements:
Clinic operations were streamlined by:

• Updating encounter forms with built-in checks for completeness.
• Integrating real-time alerts in the EHR system.
• Establishing weekly revenue cycle huddles for cross-functional alignment.

5. Credentialing Support:
Credentialing workflows were redesigned to:

• Track provider enrollment statuses effectively.
• Implement scheduling policies that prevented patient visits before enrollment completion.
• Minimize billing under non-credentialed providers.

Results:

Metric	Before	After (90 Days)
Claim Denial Rate	23%	7%
Monthly Revenue	$115,000	$160,000
Unbilled Encounters	42/month	3/month
Credentialing Processing Time	90+ days	45 days
Staff Compliance Training Completion	35%	100%

Conclusion

Through culturally sensitive and data-driven consulting, John Lynch & Associates delivered immediate and sustainable improvements in revenue cycle performance for this Tribal health clinic. The project not only restored financial stability but also paved the way for future service expansion, reinforcing the clinic’s mission to deliver quality care while honoring community values.

Client Feedback:

“The support from John Lynch & Associates was transformative. Not only did they identify critical gaps in our revenue cycle, but they also respected our unique operational needs and culture. Their approach helped us build long-term systems that will sustain our financial health and support expanded services for our community.”
— Clinic Administrator