By Jerry Godwin, MBA
Sept. 16, 2026
Over the last three articles, we’ve broken down what’s really happening inside your revenue cycle from the symptoms you feel, to the workflow gaps causing them and to the real financial impact in your practice.
Now, in part 4, we shift from awareness to action.
BEYOND ONE-TIME FIXES
Many practices fall into common traps: relying on reactive “fire drills” when cash gets tight, depending entirely on overburdened staff without documented processes or tracking no meaningful metrics beyond a monthly aging report. These approaches deliver short-term patches at best. True improvement requires intentional systems that address the entire revenue funnel from credentialing to collections.
A reliable revenue capture funnel (RCM funnel) is a proactive system designed to turn missed revenue and inconsistent collections into a predictable, controlled process. It organizes your revenue cycle into five interconnected layers.
Each layer builds on the one before it, creating redundancy and accountability that prevent small issues from becoming major leaks.
THE RCM FUNNEL
1. Foundation: Credentialing and Patient Setup
A clean claim doesn’t start when a biller clicks “submit.” It begins days, or even weeks, before the patient ever walks through your door. Every appointment relies on accurate patient information, active provider credentialing and a clear understanding of whether the visit should be billed through a vision plan or medical insurance. When those foundational pieces are in place, the rest of the revenue cycle becomes significantly easier. When they’re not, even perfectly documented claims can be delayed or denied before they have a chance to be processed.
To streamline patient check-in and minimize billing errors, keep the following two reference lists updated and accessible at the front desk and follow the key actions that need to be taken at this stage:
- Local Employer Plans: A quick-reference guide mapping prominent local businesses to their specific insurance plans and networks.
- Out-of-Network Payers: A comprehensive list of insurance plans and payers with whom your providers are not credentialed.
Key actions:
- Verify provider credentials annually and update payer portals promptly.
- Collect complete patient information (patient and subscriber DOB, insurance cards scanned, demographics double-checked) at scheduling or intake.
- Maintain an up-to-date fee schedule and payer contract matrix.
2. Pre-appointment Prep
The work you do before an appointment often determines how smoothly everything goes afterward. Taking a few minutes to verify benefits two or more days before the visit gives your team time to resolve issues before the patient arrives, rather than scrambling at check-in or after the claim has been submitted.
This is also your opportunity to set clear expectations. Confirm whether medical or vision benefits apply, identify any copays, deductibles or non-covered services, and communicate those costs to the patient ahead of time. Patients appreciate knowing what to expect. And your practice is far more likely to collect payment at the time of service if there are no surprises.
Key actions:
- Verify eligibility and benefits for every scheduled appointment.
- Document benefit details (allowed amounts, frequency limits, remaining deductible) in the patient record.
- Send previsit communications explaining financial responsibility and offering payment options.
3. Claim Creation and Submission
This is where consistency pays dividends. Every day a claim sits unsubmitted is another day your practice waits to get paid, and small delays have a way of turning into larger A/R problems over time.
The goal isn’t simply to submit claims quickly. It’s to submit them correctly the first time. That means ensuring documentation supports the services provided, coding accurately reflects the visit and clearinghouse rejections are reviewed before they become aging claims. Building these habits into your daily workflow helps keep revenue moving and prevents avoidable rework later. Even the best processes won’t catch every error, so reviewing and resubmitting rejections daily is one more step that keeps payments from sitting in your AR longer than they should.
Key actions:
- Create and submit claims daily (target should be within 24-48 hours of service).
- Perform daily claim scrubbing for completeness, modifiers, laterality and medical necessity.
- Review and correct clearinghouse rejections the same day.
- Ensure clinical documentation supports every billed service.
4. Payment & Follow-Up
Receiving a payment doesn’t necessarily mean the job is finished. Some of the biggest revenue leaks happen after the claim has been processed, when underpayments, downcoding, bundled services or unresolved denials go unnoticed.
Every ERA should be reviewed with the same level of attention you gave when the claim was submitted. If a payment doesn’t match what was billed, ask why. If a denial can be appealed, work it. And, if you begin seeing the same denial reasons repeatedly, use that information to improve the process, not just resolve the individual claim.
Key actions:
- Post payments and review ERAs within 48 hours.
- Watch for remark codes showing a reduction or adjustment of billed codes.
- Appeal underpayments, downcoding, and bundling issues systematically.
- Bill secondary payers and patient responsibilities quickly.
- Perform root-cause analysis on denials to prevent recurrence (no automatic write-offs).
5. Accountability Review
Regular oversight with clear KPIs turns your stack into a measurable engine. Set aside time at least twice each month to review key performance indicators with ownership or practice leadership. Looking at these metrics consistently helps identify problems early, measure improvement over time and keep everyone aligned around the same goals.
Key benchmarks for a healthy optometry practice, sourced from industry standards1 and our experience:
- Days in A/R: under 35
- Average unpaid A/R (claims and sales) ÷ average daily charges. It tells you how many days of production are still sitting uncollected, not which aging bucket the money is in.
- Net collection rate: 95% or better
- This asks: of the money you were contractually owed after payer discounts, how much did you actually collect? Bad debt, missed appeals and sloppy write-offs will pull this number down.
- Initial denial rate: under 8% of claims on first submission
- That 8% figure is the one commonly cited from MGMA single-specialty data.2 It is pulled from clearinghouse rejections and ERA denial codes, not from what finally got paid after you reworked the claim.
- A/R over 90 days: under 8-15% of total outstanding A/R
- This is a measure of what is uncollected. 8% is a stretch goal. Anything under 15% is a more common healthy ceiling. Once balances cross 90 days, collectability drops fast.
- Point-of-service collections: 30-40% if estimated patient responsibility
- This is not 30-40% of total practice revenue. It is the share of the patient’s estimated portion—copay plus expected deductible or coinsurance—that is collected before they walk out.
FROM UNPREDICTABLE TO RELIABLE
Intentional A/R management transforms revenue from unpredictable to reliable. By shifting from reactive habits to a proactive, measured RCM Funnel, practices gain better cash flow, reduced stress and the ability to focus on patient care and growth rather than chasing payments.
Start small: Pick one layer (such as pre-appointment verification or daily claim scrubbing), implement the relevant checklist for 30 days, track your KPIs and measure the difference. Build momentum layer by layer. Consistency beats perfection every time.
CLOSE YOUR WORKFLOW GAPS
Staffing shortages, intricate payer rules and daily operational demands can create workflow gaps even within well-structured practices. Many practices benefit from external support for independent A/R analysis, staff training, denial management expertise or full outsourced RCM.
The series ends here, but your improved revenue cycle is just beginning. Don’t settle for “good enough.” With the right stack in place, consistent cash flow and practice stability are well within reach.
References
1. https://www.optivatehealth.com/white-paper-rcm-benchmarks-2026
Catch up on Jerry Godwin’s series
Part 1: The Silent Cash Flow Killer
Part 2: Where Revenue Is Won or Lost
Part 3: The Hidden Costs of ‘Good Enough’ AR Management
Read more on coding and billing here
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Jerry Godwin, MBA, is president of OMS. With over 20 years of experience in healthcare, Godwin’s diverse background makes him an expert in business infrastructure development, practice management, revenue cycle management and education for medical eyecare implementation. He invites readers to take the free Revenue Health Quiz to identify your biggest opportunities or for a no-obligation discussion about building your own reliable RCM Funnel. |
