Improving Revenue Integrity for a Tribal Health Clinic
Case Study.
Project Overview
Market: Tribal Health
Primary Service: Practice Management
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- Compliance Gaps stemming from outdated policies and lack of internal audits.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
To overcome these challenges, the following solutions were implemented: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.
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.
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.
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.
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% |