Make-up sessions that never get made up
“No problem, we’ll get that made up.”
Said in good faith, every day, in every ABA practice. It ends the awkward part of the call, the parent feels better, the front desk moves on.
Then somebody has to find an hour that works for a family, a clinician, a room and an authorization, in a schedule that was already full. That is four constraints, and the offer was made by someone holding none of them.
Why the rate is so low
Ask a practice owner what proportion of cancelled sessions get made up and you will usually hear something between 40 and 60 percent. Measure it and it is typically under 20.
The gap is not dishonesty. It is that nobody is counting, and the ones that do get made up are memorable while the ones that quietly do not are not.
The structural reasons are straightforward. A make-up session needs capacity that by definition does not exist in a well-utilised schedule. It needs the same clinician, usually, for continuity. It needs to land inside the authorization span, and inside any weekly cap — which means a make-up in a week that was already at the cap cannot be billed at all, and that is a detail nobody checks at the point of offering.
And it has no owner. The offer is made at the front desk. The scheduling is done by someone else. The follow-up belongs to nobody.
What the difference is worth
Illustrative arithmetic, not a client engagement.
The $66,300 is not a leak in the usual sense. The money was already lost when the session was cancelled. What the gap costs you is accuracy — a forecast built on a 50 percent make-up rate is overstating revenue by about $66,000 a year, and the overstatement shows up as cash that does not arrive.
That is a different kind of damage from a leak and it is worth naming separately. It is not money you can go and get. It is a number you should stop counting on.
Counting it properly
A make-up is a session that happened because a prior session did not. That is a link between two records, and almost no practice management system creates it automatically.
So you need a flag. When a session is scheduled as a make-up, it gets marked as one, with a reference to the cancelled session it replaces. One field, one dropdown, set at the point of scheduling.
Then the report is a count: cancelled sessions in a period, make-up sessions linked to them, divided. Run it monthly.
Without the flag you can approximate it — extra hours delivered in a week above the client’s standard schedule — but it is noisy, because some of those hours are genuine schedule increases and some are catch-up from a different cause. The flag is worth the fifteen seconds.
The better fix
Stop offering make-ups you cannot deliver.
That sounds harsh and it is the opposite. A make-up offered and not delivered is worse for the family than one never offered, because they planned around it. Two of those and the practice’s word stops meaning much.
The workable version is a small, protected block of make-up capacity — a couple of hours a week per clinician that are not scheduled with a standing client. It reduces headline utilisation slightly and it means the offer is real. Practices that do this tend to land make-up rates in the 40s, which is where everyone thought they already were.
And when the block is full, the answer is “we can look at next week,” not “no problem.”
The authorization trap
One more thing, because it is the one that turns a good deed into a denial.
A make-up session delivered in a week that is already at the authorization’s weekly cap will not pay. The units are there in total, the week is not. So the session happens, the clinician is paid, and the claim denies against a limit nobody checked.
If your authorizations carry weekly caps — and stage 02 covers how to find out — the make-up needs to land in a week with room, not just inside the span.
Five checks you can run this week
1. Add the make-up flag with a reference to the cancelled session. One field. Nothing else in this post works without it.
2. Ask three people in the practice what the make-up rate is, then measure it. The size of the gap between belief and measurement is itself the finding.
3. Check your forecast for an assumed make-up rate. If one is baked in above 20 percent, the forecast is overstating revenue.
4. Pull denials coded to unit or weekly limits and check how many were make-up sessions. This is a small number that is very annoying to discover late.
5. Try a protected block for one month with two clinicians. Measure the make-up rate for them against everyone else. It is a cheap experiment and it usually settles the argument.
The number to actually track
Make-up capture rate — make-up sessions delivered over cancelled sessions eligible for one.
Pair it with whatever make-up rate is baked into your revenue forecast. If the forecast assumes more than 20 percent and nobody has measured it, the forecast is overstating cash.
Counting offers rather than deliveries measures good intentions.
Where this sits
This is the third of eight stages where ABA revenue leaves. Stage 01 is the reservoir and stage 02 is authorization burn. Cancellations are the gap between a session that should have happened and one that did.
This is the part of the stage that costs you accuracy rather than money — the money left when the session was cancelled.
A Leak Map Assessment measures all eight — the reservoir, authorization burn, cancellations, session conversion, conversion to billed, clean claims, rate integrity and recoupments. A claims audit is a different instrument. It starts once a session has been converted and billed, and reconciles the back half of the cycle to cash.
Aimline closes the books, oversees the revenue cycle, and sits in the CFO seat for ABA practices. We run claims audits scoped to a payer book, and Leak Map Assessments that measure the full cycle — three weeks, $7,500 fixed. Either one gives us a verified number to run oversight against, and the report is yours whether or not you engage us to fix what it finds.
