Three Rivers Health Put Its Turnaround on Worksheet G

A ten-bed hospital in Big Horn County, Wyoming closed its fiscal 2023 books with $108,917 in the bank and $6,713,386 in accounts receivable.

Measured against its own operating expense that year, the cash side of that is 3.4 days.

Two years later the same two lines on the same form read $3,816,084 and $2,888,085.

Three Rivers Health, which is the d/b/a of the South Big Horn County Hospital District, has been telling the story of how that happened, and HFMA ran it on October 12.

The part worth your time is that the whole thing is checkable, because a hospital that files a Medicare cost report files its balance sheet with it.

What the Hospital Says Happened

Joel Jackson became CEO in April 2023. The hospital had no CFO, a Cerner implementation underway, and roughly $6 million of accounts receivable that had been sitting for at least two years.

Jackson's own description of the position: "We were in a really tenuous cash position and it's fair to say we could have closed."

The scoreboard the hospital and its revenue cycle partner have published since:

$2.6 million recovered from the claims backlog by the end of an initial 15-month extended business office engagement
A/R days from 147 in April 2023 to 57 in April 2025
Days cash on hand from 6 in July 2023 to 111 in May 2025
Revenue from $14.1 million in FY2023 to $18.1 million in FY2025

The operational moves behind it were unglamorous and specific: the backlog, coding and denials went to TruBridge under an extended business office model and later a full business office one, the CFO went through National Rural Health Association training, and the leadership team sat through a cost-reporting class.

Those figures come from the hospital and from its vendor. So we went and pulled the filings.

What the Filings Say

Three Rivers is CCN 531301 in the CMS Hospital Provider Cost Report files, facility type CAH, 10 beds every year, fiscal years ending June 30. Five consecutive final files carry it.

Cash on hand is G-Line-1. Accounts receivable is G-Line-4, and the uncollectible allowance against it is G-Line-6.

Patient revenue, operating expense and net income are lines 1, 4 and 29 of G-3.

Here is what those lines hold, straight across:

Cash: $3,286,534, then $919,398, then $108,917, then $337,052, then $3,816,084
Gross A/R: $6,713,386 at the June 2023 year end down to $2,888,085 two years later, a $3,825,301 reduction, of which $2,323,017 came off in fiscal 2024 alone
Total patient revenue: $14,130,262 in FY2023 to $18,247,029 in FY2025, up 29.1%

Turn the first two into days and the shape of the thing shows up (chart below). Net A/R peaked at 262 days at the June 2023 year end, three months after Jackson took the job, in the same report where cash bottomed at 3.4 days.

By June 2025 A/R is at 63 days and cash is at 121. The two measures crossed and crossed back inside two fiscal years.

Pick Your Denominator

A/R days is a ratio with an argument in it, and the argument is what you divide by.

Divide net A/R by gross charges and Three Rivers runs 140 days at the June 2023 close and 32 at June 2025. Divide by net patient revenue and the same two reports give 262 and 63.

The published 147 to 57 sits inside that range at both ends. Either denominator tells you the same story, and neither one is wrong, which is the useful thing to know before you compare your own number to somebody else's.

The revenue pair deserves the same care, because $14.1 million to $18.1 million is gross charges on G3-Line-1.

Net patient revenue, two lines down, went $7,546,266 to $9,308,718, up 23.4%.

Final Thoughts

The balance sheet moved further than the income statement did. Long-term liabilities came down from $10,967,246 at the June 2023 close to $4,646,418 two years later, fund balance went from $4,578,331 to $10,585,618 in the final year alone, and net income for FY2025 still landed at -$114,246 after $2,070,120 of other income.

A critical access hospital in a county hospital district lives on that other income. Board chair Jeff Petty wrote publicly in July that Wyoming's 2025 homeowner exemption, which took 25% of the first $1 million of fair market value off the rolls with no state backfill, cut a quarter of the county assessment.

Which is what 121 days of cash is actually for.

The reusable part here is the method. Any hospital that tells you it fixed its receivables has already told Medicare the same thing in a file you can download for free, with the balance sheet, the revenue lines and the fiscal year end all in one row, keyed to a CCN.

Three Rivers Health's row agrees with its press.

Thanks for reading.