ERA Series — Part Two (Field Notes): On Resistance, Pebbles, and Quiet Change

In my last post I said ERAs can teach us where to look. That part is true.

What I didn’t say out loud is what happens next: people have to carry the change.

It’s easy for an RCM consultant to circle dollars on a spreadsheet. It’s harder for the front desk to add eligibility checks to a morning that already starts at a sprint. More clicks. One more portal. One more phone tree. It’s not laziness; it’s gravity. Work expands to the edges of the day.

That tension reminded me of my son’s elementary school.

His teacher kept a jar in the middle of the room. When a child noticed another being kind or brave, they raised their hand; the teacher named the moment, and a pebble went into the jar. If the class finished tidying before the last bar of the flute song, a few more pebbles. When the jar filled, there were cupcakes. Simple. Visible. Everyone’s win.

Around the same time, I took a course with Professor Uri Gneezy on incentives. He said what we all know and forget: people do more of what is noticed, named, and rewarded—especially when the reward feels fair and shared.

Those two memories—pebbles and incentives—meet me again as I watch a practice wrestle with the “after” of ERA awareness. We can see the preventable denials clearly; we can even sort them by dollar impact. But clarity doesn’t make the new habits any lighter. The front desk still has the same hands and the same hours.

So here’s a small, human experiment I can imagine trying.

We put a clear jar on the counter by scheduling—not literal pebbles, but a simple shared tally. Every time someone catches an inactive eligibility before the visit, we write it down. When someone obtains a required prior authorization before scheduling, we write that down too. When a credentialing mismatch is fixed and a claim finally moves, it goes on the list. Each entry has the date, patient initials, payer, reason prevented, and dollars at risk (the allowed amount, not the charge—thank you, Casey, for catching that blind spot).

If this idea takes root, here’s what I imagine might follow.

Maybe, on Fridays, the team pauses for a few minutes to look at the week together. No scolding, no spreadsheets in red—just small acknowledgments:

“You caught three inactives on Tuesday; those three families will never get a surprise bill.”

A jar slowly filling, one line or pebble at a time.

And at month end, perhaps the practice decides to share a small percentage of the avoided write-offs and rework saved back with the team. Cash, not pizza. Transparent math. Nothing extravagant—just enough to say, “We see you. This mattered.”

For someone who values time over money, maybe it becomes an hour off next month instead. Not everyone needs the same pebble. But everyone can feel that small, visible loop of effort turning into shared reward.

What might change?

Maybe not everything at first. But I can imagine the room starting to feel a little different. People comparing notes on how to spot inactives faster. Someone creating a one-page prior auth cheat list by payer and taping it where the eyes already go. Another building a tiny morning checklist: tomorrow’s schedule → eligibility run → sticky flag in the EHR. No one waiting for permission—just small, thoughtful steps that make the work lighter and smarter.

That’s the hope. That’s the experiment.

A few reflections from the side of the room:

• Naming helps. “Preventable denial” is abstract; “we spared this patient a surprise bill” is concrete. A jar (or shared tally) helps everyone see the invisible.
  
  

• Fairness matters. People accept extra steps when the benefits don’t disappear into a general ledger. A small, visible share says, “Your effort moved the needle.”
  
  

• Tools help, but they don’t substitute. Batch eligibility would be lovely; until then, a ritual and a list carry the day. If your clearinghouse offers 270/271 in batch, great. If not, light RPA can press the same keys you do. But the pebble habit stays.
  
  

• Kaizen over crusades. Don’t aim for zero denials; aim for fewer this Friday than last Friday. That’s a goal a human can hold.
  
  

I still believe it’s cheaper in healthcare to think a little longer than to rework the same claim twice. Eligibility, prior auth, credentialing—these aren’t villainous mysteries; they’re ordinary chores that benefit from rhythm and respect.

So when a practice “listens to their ERAs,” the real work isn’t a dashboard; it’s a culture. It’s a room where someone can say, “I found an inactive,” and someone answers, “Thank you,” and a small pebble drops into a jar everyone can see.

Will this scale? I don’t know yet. I know it’s honest. And I know patients who never see a surprise bill trust you more—and that trust is the kind of revenue you can’t post but you can feel. That’s how a community becomes a community.

If you try a version of this, make it yours. Maybe your jar is a shared Google Sheet. Maybe your “pebble” is a green dot on a wall calendar. Maybe your reward is Friday early leave instead of dollars. Whatever you choose, keep two promises: make wins visible and share the benefit.