6 Keys To Success In Revenue Cycle Management

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2 Min

The Out-of-Network VS. In-Network world in healthcare is changing
Source: Wakefield
April 19, 2024

The lack of time and resources to adequately manage the revenue cycle, typically leads providers to issues like poor cash flow, aged receivables, and increased denials.


You may experience issues like:

  • Low Cash Flow
  • Aged Receivables
  • Missed Charges
  • Reduced Front End Collections
  • Increased Denials
  • Poor Workflow
  • Risk of Non-Compliance
  • Payor Tactics to Reduce Reimbursements

Lately, market issues confirm this as well. This chart shows the issues providers are receiving, and the reasons why it could be happening.

5-10% of AR is lost because the payor never processed itUnprocessed claims, missing documentation, and denials
Underpaid claims are not properly appealedIn-network, out-of-network and medicare
30-40% loss in Individual out-of-network claimsNo data, no time, no expertise
Billing systems geared towards billing, not collectionsAR tracking done in spreadsheets, where claims slip through the cracks
Lack of ReportingKPI analysis, staff productivity, claim status

All these holes in payer collections can add up to a gigantic losses in revenue for providers.

The recurring theme of our payor reimbursement solution is every claim, every time.  Oftentimes, AR companies want to write off AR balances quickly.  But we’ve found that one of our biggest keys to success is to make sure each one of your claims is properly monitored, processed, and reconciled so your money’s in the bank.

How can you take this information and apply it to your own practice? Here are the 6 keys you need to know:


1. Understanding Payor Tactics

The first key is understanding payer tactics to reduce reimbursements.

Part of our “secret sauce” is the depth of our knowledge of how out-of-network reimbursements work from the insurance company’s perspective. Our team comes from every major payer and vendor, and we handle over $1.3 billion in out-of-network bills each year.

Take it from us: to be successful, it’s important to know…

  • When it’s best to write or call the payor
  • What are the best arguments to make
  • How to read an EOB
  • Whether to escalate internally at the payor or externally, like with the state insurance commission or US Department of Labor

We like to say we see more out-of-network claims than anybody else in the country. We know how to work these claims because we’ve seen them before. Take our word for it!

2. Technology

Many providers encounter issues with their revenue cycle because it’s a manual, time-consuming process. They spend too much time identifying issues with AR rather than fixing them because they have to individually check every account’s 835 data. They resort to spreadsheets or restrictive software to keep organized  And they have to make multiple calls on each account just to get the status.

This limits your capabilities, visibility, and revenue potential. Instead, invest in industry-leading technology. Here’s an example of the technology we offer, and why it’s so critical you move away from those manual processes.

6 keys

CRXIS, our business intelligence engine, serves as one of the largest out-of-network databases in the industry. No other revenue cycle company has as much information as we do.

We’ve developed this technology to enhance payor reimbursements by automating A/R Follow-Up, maximizing out-of-network reimbursements, and providing analytics & reporting.

CRXIS allows us to:

  • analyze actual insurance policies throughout the country to determine what is “reasonable and customary”.  By analyzing these insurance policies, we are able to get a detailed understanding of plan types and language defining “usual and customary”.  For example, they may want to pay 110% of Medicare, but the policy might say “reasonable and customary” is what similar facilities in the community charge.  We don’t just rely on what the insurance company says.  We go straight to the source.
  • send claims to the right person at the right time for follow up. It identifies those claims with the highest likelihood to provide additional payments and sends them to our staff for follow up, ensuring that regardless of the volume of claims, we are working the ones most likely to impact revenue.
  • use data and analytics from over 4500+ customers to compare our determination of R&C with the payor and, in many cases, we’re able to identify “holes” in their data and convince the payor to increase their payment.

And that’s just scratching the surface. Can your billing company or in-house billing team do that?

3. Data Reconciliation

We found that when we follow behind another billing company or inhouse billing, there are many missed encounters which can lead to 5-10% missed revenue in AR follow up alone. So it’s important to put multiple checks in place to ensure that every single claim has been followed up on, processed by the insurance company, and there is money in the bank.

accounts receivable

Here’s an example of a common mistake made by many providers when they are not taking the time to capture each encounter accurately and failing to reconcile billed claims to payment.

Daily billed claims20
Claims processed successfully17
Claims not processed3
Lost revenue/encounter not charged$3,000
Total lost daily revenue$9,000
Total lost monthly revenue$180,000

In this example, the provider billed 20 encounters and 17 of them were successfully processed by the insurance company.  But because the provider did not diligently follow up, the other 3 encounters were never processed by the insurance company.  If each of these encounters were worth $3,000, this would result in $9,000 of missed revenue just that day.  Now think if this error occurred every day, it could result in a $180,000 loss of revenue throughout the entire month!

The point is, even missing only one charge per day can add up to significant dollars lost in the long term.

4. Workflow Optimization

Understanding workflow is critical because the most common issues on the back end of collections are caused by breakdowns in the early parts of the revenue cycle, like clinical denials or incorrect 837 data. Workflow optimization can help with:

  • Onsite assessments and recommendations regarding process improvement
  • Impact on revenue
  • Improving staff time management

We’ve automated AR workflow by identifying “at-risk” accounts so an FTE doesn’t have to spend the time doing so!

5. Data & Analytics

We like to use the term “actionable data”. Can you identify root cause issues and solutions? Can you data mine different methodologies that improve financial performance? Can you anticipate trends or projects? Can you determine revenue impact, or how your bottom line is performing?

This information is absolutely integral to the financial health of your organization.

data analytics

We can pull reports like this on a weekly, monthly, or ad hoc basis to help you make more informed financial decisions quickly & manage the cost to collect.

The issue with any billing system is they’re limited to the canned reports they provide. With Collect Rx, if you are ever interested in a report our system does not have, let us know and we may be able to create it externally!

6. Out-of-Network Expertise

The opportunity to increase out-of-network payments is so great that it can have a tremendous impact on your bottom-line. Think about it.  There aren’t a lot of opportunities to increase reimbursements rates.  Contracted and fee-schedule rates are already fixed. Out-of-network is the only area left where you can increase rates and improve the bottom-line.


One of the biggest complaints we hear from providers is their billing company is holding their information hostage. Remarkably, the provider is unable to retrieve their own EOBs or reports from their billing company. Remember, this is your data, and these are your accounts. Collect Rx will make sure that you have full access to all of your information.