Why are our collections falling?

Start by ruling out the obvious

Before diagnosing billing, confirm the inputs have not changed. Compare this period against the same period last year, not last month — most practices have seasonal patterns that look alarming month over month.

• Is patient volume the same?
• Is your payer mix the same? A shift toward a lower-paying plan reduces collections with nothing wrong in billing.
• Has your service mix changed? Fewer high-value procedures moves revenue without moving visit counts.

If volume and mix are steady and collections are down, the cause is in the revenue cycle. The rest of this page is about finding where.

The six causes, and how to tell them apart

1. Claims are going out slower

Check the gap between charge entry and submission. If it has drifted from two days to seven, your deposits move back a week and keep moving until it stabilises. This is the easiest cause to confirm and the easiest to fix.

2. Denials are not being worked

Check A/R over 90 days as a percentage of total A/R. Under 15–20% is commonly cited as acceptable, under 5–10% as healthy. Rising means claims are ageing because nobody is chasing them, and resubmitting is not working them.

3. A payer changed something

Look for a denial reason that barely existed three months ago and is now in your top three. Payers change policy, documentation requirements and fee schedules with minimal notice, and a single change on a common code moves revenue quickly.

4. A credentialing lapse

Check that every provider is currently enrolled with every payer you bill. A lapsed enrolment produces a wave of denials weeks after the fact, and many payers will not backdate — so this one can be partly unrecoverable by the time you notice.

5. Patient balances are not being collected

As deductibles and coinsurance have grown, patient responsibility has become a large share of collections. If statements are not going out or nobody is following up, that revenue simply does not arrive and it does not appear in any denial report.

6. Underpayments nobody is checking

The quiet one. A payer paying below the contracted rate looks exactly like a payer paying correctly unless somebody compares line by line at CPT level. This does not show as a denial or an aged claim — the money just never arrives.

How to work out which you have

Pull an A/R aging report by payer and bucket, and a denial report for the last three months. Between them they separate all six.

• A/R over 90 days rising, denials flat → cause 2, follow-up has stopped.
• One denial reason suddenly dominant → cause 3 or 4.
• A/R healthy, collections still down → cause 5 or 6, look at patient balances and contracted rates.
• Everything looks fine on both reports → check submission lag first, then revisit whether volume or mix really is unchanged.

The nine-point framework covers this properly, with the specific report to pull for each check.