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Don’t miss an opportunity to improve revenue by identifying collection breakdowns in office processes
By Jerry Godwin
June 3, 2026
You can’t fix what you can’t see. In optometry, patients don’t always realize how much their vision has changed until it’s tested with an exam. The same thing can happen in your revenue cycle.
In my previous article, we talked about the common symptoms of poor AR management. These symptoms often show up as strong production but weak cash flow, increased AR balances and the general feeling that something might be amiss. But these symptoms don’t always identify where the breakdown is happening.
This is where many practices get stuck. To really understand what’s going on, you have to step back and look at the entire workflow from beginning to end. When you’re in the middle of daily operations, it’s easy to focus on fixing a specific symptom rather than the systemic bottleneck.
Every Dollar Follows the Same Path
Whether it’s a routine exam or a more complex medical visit, every dollar your practice earns follows the same general path:
- Front desk, with scheduling, demographics and insurance verification
- Pretesting into the exam room, where care is delivered and documented
- Exam room into the optical to check-out, where invoices are created and the patient responsibilities are collected
- Claims are created and pushed to billing, where claims are scrubbed, submitted and tracked
- Rejections are managed, and the process moves into payment and reconciliation, where revenue is actually realized
When everything is working smoothly, that process feels fluid. But when one step breaks down, the workflow error doesn’t stay contained. It trickles down to your bottom line.
Let’s follow a claim from check in to check out and identify the tasks in the process that typically trigger revenue issues down the line.
Step 1: It Starts Before the Patient Walks In
A patient schedules an appointment. Insurance information is collected and entered into the system. At a glance, everything looks complete, but if demographics are not accurate, benefits aren’t verified ahead of time or if medical and vision coverage are confused, the foundation to get reimbursed is not established. These issues show up later when the claim is rejected at the clearinghouse or denied by the payer.
Chart courtesy of Jerry Godwin
What feels like a simple front desk task is actually one of the most important drivers of a clean claim. When this step is rushed or mistakes go unnoticed, the entire process downstream breaks down when trying to file the claim.
Patient Scheduling and Arrival Checklist
- Verify insured name and DOB, collect insurance information (medical & vision)
- Member ID and Group # entered correctly into system
- Benefits for Medical and Vision plans verified prior to visit
- Confirm all patient info at check in and communicate benefit coverages
- Insurance cards scanned into system and attached to patient record
Step 2: The Exam and Documentation
The patient is seen and care is delivered. From there, the success of the claim hinges on how that visit is documented and coded.
If the distinction between medical and vision isn’t clearly established, or if documentation lacks specificity, the claim may still be filed, but not accepted or processed by the payer correctly.
This is where we often see:
- Services provided but not clearly documented or supported in the record
- Diagnosis codes missing specificity
- Laterality not documented
- Modifiers not linked correctly for invoicing
- Documentation that does not support what was filed on the claim
- Routine vision diagnosis reported to medical payers
The tricky part is that these issues don’t always stop a claim from being paid. Instead, they often result in reduced reimbursement or denials that can’t be corrected later. Revenue isn’t just lost here, it’s often never fully recognized in the first place. And in some instances, can be recouped by the Payer if the records do not accurately reflect the services filed on the claim.
Step 3: Check-Out and Patient Responsibility
At check-out, the visit is finalized and the financial side of the encounter comes into focus. If patient responsibility isn’t clearly communicated or collected at this point, it becomes significantly harder to recover later. Statistics show that if patient responsibilities are not collected at the check out, the collectability drops by 62% leaving a 38% collectability rate.1
At the moment, it might not feel urgent to collect at the time of service. The patient is ready to leave, and the front desk is busy. There’s always another task waiting. Yet the cost of collection rises 5 times after the patient leaves the practice.
This is where:
- Vision or medical billing is based on doctor’s diagnosis
- Financial responsibility is not communicated
- Copays and deductibles go uncollected
- Patient responsibilities are pushed off to later: “We will send you a statement after we file the claim”
- Claims are left incomplete or unclear due to improper benefits or documentation
What gets skipped here doesn’t disappear. Uncollected AR requires follow-up, staff time and often uncomfortable patient conversations later. Payment at time of service is critical.
Step 4: Claim Submission and Follow-Up
The claim is created and submitted. This is where many practices assume the process is largely complete, but consistency here matters more than most realize. When a single step in the process fails, the errors cascade through the process impacting your bottom line profitability.
The most common claim errors are:
- Invoices “sitting” in the system incomplete not pushed to a claim to be filed
- Rejections are not reviewed, corrected and refiled
- Secondary claims are missed entirely
- Missing modifiers
- Incorrect Payer ID for insurance carrier
- Clearinghouse rejections are ignored, not worked, and refiled
- Missed payer deadlines (claims age out)
Each delay reduces the likelihood of full reimbursement and increases the effort required to recover the revenue. And as these errors pile up, it’s less likely they will be attended to.
A dedicated biller in your office should follow this checklist to ensure claims are submitted correctly and followed up upon as needed:
- Create and submit claims within 24 hours of service
- Confirm all required fields are complete and accurate before submission
- Validate correct CPT, ICD-10 and modifiers
- Ensure exam documentation supports services billed
- Review clearinghouse rejection reports daily
- Correct errors and resubmit claims daily
- Identify recurring rejection patterns
- Escalate systemic issues to the team and train for correction
- Confirm exam notes support medical necessity
- Verify laterality and diagnosis specificity
- Ensure CPT coding aligns with documentation (treatment plans, interpretation and reports)
- Address documentation gaps before resubmission
Step 5: Payment and Reconciliation
Payments begin to come in, and accounts are updated. At a high level, everything appears to be working. However, this is where some of the most meaningful revenue loss occurs.
Payments are often posted without being reviewed against what was originally billed. Downcoding, bundling and partial payments go unnoticed and denials are at times written off instead of worked. The biggest issues we see during payment and reconciliation include:
- Payments not posted promptly
- Partial payments not followed up or transferred to the responsible party
- Patient statements not sent out avoiding patient responsibilities
- Secondary claims never submitted
- Medical record documentation not supporting the claim
- Denials adjusted off instead of worked
- Not identifying the root cause of denials to prevent future denials
Sometimes, teams are simply unaware of the problems; other times, they lack the time and resources to address them. Regardless of the cause, the outcome is identical: the practice leaves money on the table.
THE BIG PICTURE
If your practice sees around 20 patients a day, you’re conservatively generating about $70,000 in revenue.
Now layer in a few common gaps:
- Uncollected patient responsibilities
- Unworked claims rejections
- Unworked denials and refiling of claims
- Underpaid claims
- Delayed or unsubmitted claims
Even small inefficiencies across each of these areas can add up to $15,000 or greater per month in lost or delayed revenue.
Next, I’ll take a look at a few practice scenarios and how these breakdowns add up and affect revenue.
References
Read more on AR management here.
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 eye care implementation. |
