Intensive outpatient
An IOP program that stopped delivering care outside its authorizations
Sixty clients, two tracks, and an authorization spreadsheet reviewed on Mondays. The sessions delivered on Wednesday after a visit limit ran out were never coming back.
- Level of care
- Intensive outpatient
- Size
- 60 active clients
- Payer mix
- Commercial, Medicaid MCO
- Focus
- Authorizations and denials
The situation
Authorizations were tracked in a shared spreadsheet updated by the utilization review coordinator, usually on Monday. The front desk booked appointments in the EHR, which knew nothing about visit limits.
The result was predictable and repeated monthly: sessions delivered after a limit was exhausted or a date range expired. Those claims deny, and unlike most denials they do not win on appeal — the payer's position is not that the care was poor, it is that it was never approved.
What changed
- Remaining visits appeared on the booking screenThe person creating the appointment sees what the utilization reviewer sees.
- Alerts fired on thresholds, not on a scheduleVisits remaining, dollars remaining and days to expiry, warned before the wall rather than after it.
- Continued-stay requests became a tracked queueSubmitted, with reviewer, approved, expiring — instead of a column in a spreadsheet.
- Denials landed in a worklist with deadlinesReason, dollars at risk, appeal-by date and a named owner on every item.
Results
Three measures, before and after.
The largest single denial category, addressed at the booking screen.
A queue with deadlines and owners recovers what a shared tab loses.
Denials worked by value and deadline rather than by whoever had time.
This is a composite scenario, modelled on the workflows this product was designed against with a clinic director and a revenue cycle management firm. It is not a named customer engagement, and we will replace it with one when a program is ready to publish under its own name.
The takeaway
Care delivered outside an authorization is the one loss you cannot appeal your way out of. Prevention is the only strategy.
If that describes your program, the fastest way to find out whether this holds is thirty minutes with your own workflows rather than a slide deck.
More case studies
Other levels of care.
Residential treatment
Forty beds, one records request, and three days nobody had
A commercial payer asked for six months of charts on four patients. The program had the care documented and still nearly lost the argument on paperwork.
Detox & withdrawal management
A detox unit that stopped losing bed-days to its own whiteboard
Sixteen beds, a paper census, and a per-diem claim rebuilt by hand every month. The gap between beds occupied and days billed turned out to be the whole problem.
Partial hospitalization
A PHP program where attendance and billing finally agreed
Group-heavy days, per-diem billing, and three separate records of who was actually in the room. The disagreements between them were costing more than the no-shows.
Get started
Start today, or take a look first.
Create an account in minutes. Or book a 30-minute walkthrough.