The average medical practice loses 15–20% of collectible revenue annually to preventable revenue cycle failures (MGMA; Capline Healthcare 2025). For a practice collecting $1,000,000/year, that's $150,000–$200,000 walking out the door. This worksheet identifies exactly where your leaks are.
How to use this worksheet: Circle or check the answer that best describes your practice today. Add up your points by category, then total all categories for your overall score. Match your score to the tier table at the end.
Scoring: 3 pts = best practice | 2 pts = average, room for improvement | 1 pt = below average, significant risk | 0 pts = not in place / critical gap
Category 1: Front-End Eligibility (9 points)
27% of claim denials trace to eligibility errors — the single largest preventable category (MGMA). For a $1M practice, eligibility failures alone account for $27,000–$40,000 in annual revenue loss.
348–72 hours before every appointment via real-time eligibility tool
2Day-before batch verification for most patients
1At check-in only, manually from patient's card
0Only when a claim denies for eligibility reasons
3<2% of claims deny for eligibility reasons
22–5% eligibility denials
15–10% eligibility denials
0>10%, or I don't track this separately
3COB confirmed at every visit via standard protocol; primary/secondary order verified
2COB reviewed when patient reports two insurances; not systematically verified
1COB handled reactively when a denial occurs
0No formal COB process; handled ad hoc
Category 2: Coding Accuracy (9 points)
E/M undercoding alone costs the average practice 5–10% of E/M revenue. Coding-related denials account for 13% of total revenue cycle leakage (MGMA January 2026 poll).
3Provider trained on 2021 AMA E/M guidelines; documentation reviewed by certified coder; <1% coding denials
2Provider selects code; periodic coder review; some undercoding identified in audits
1Provider selects code; no external review; significant undercoding likely
0No training on current E/M guidelines; undercoding rate unknown
3Auth obtained before every scheduled procedure; verified against provider NPI, DOS, and CPT before claim submission
2Auth obtained for known high-auth procedures; occasional misses occur
1Auth obtained reactively after a denial; frequent rework
0No systematic auth tracking; PA denials are a chronic problem
3Automated scrubber catches NCCI edits, modifier errors, and LCD mismatches; >95% clean claim rate
2Clearinghouse edits catch some errors; NCCI/modifier errors still get through
1Manual review only; biller catches what they catch
0No pre-submission scrubbing; claims go directly to payer
Category 3: Denial Management (9 points)
$262 billion in claims are denied annually in the US (HFMA). 50–65% of denied claims are never reworked (MGMA) — meaning most preventable denials become permanent revenue loss.
3>90% of denials are appealed or resubmitted; denial rework is a tracked KPI
260–90% of denials get reworked; some fall through the cracks
130–60% reworked; significant write-offs from abandoned denials
0<30% reworked, or I don't track this at all
3Monthly denial analysis by CARC code, payer, and provider; root cause report drives process changes
2Denial codes tracked in PM system; periodic review; some process changes result
1Denial codes visible but not analyzed systematically
0No denial root cause tracking
3Denied claims identified and assigned within 24 hours; resolved within 14 days
2Denied claims worked within 30 days
1Denied claims worked within 60 days; some timely filing risk on rework
0>60 days or no defined process; timely filing denials occur on reworked claims
Category 4: AR Follow-Up (9 points)
Claims beyond 120 days have <50% probability of collection (MD Clarity). Net revenue leakage from unpursued AR = approximately 3–8% of collectible revenue for average practices.
3<35 days (top quartile for most specialties)
235–50 days (industry average range)
150–65 days (below average; cash flow strain likely)
0>65 days, or I don't know my Days in AR
3<8% of AR is >120 days (top quartile)
28–15% of AR is >120 days (industry average)
115–25% of AR is >120 days (below average)
0>25% of AR is >120 days — collection probability on this balance is <50%
3All unpaid claims followed up at 30-day intervals; payer-specific protocols; status documented per claim
2High-balance claims followed up proactively; lower-balance claims worked reactively
1Follow-up happens when AR report is run; no outreach cadence
0Reactive only — only follows up when claim denies or patient calls
Category 5: Contract Compliance & Underpayments (9 points)
Commercial payer underpayments cost providers 1–3% of net patient revenue annually (Becker's); some studies put it as high as 11%. For a $1M practice, that's $10,000–$110,000 in missed revenue per year — accepted silently.
3Quarterly contract compliance audit; underpayments identified and appealed within 90 days
2Annual audit; some underpayments identified
1Audit performed once (at contract signing) — never since
0No fee schedule loaded; no contract compliance audit ever performed
3Fee schedules updated within past 6 months for all payers; discrepancies flagged automatically
2Fee schedules loaded but may be 1–2 years out of date for some payers
1Some payers have fee schedules; underpayments are accepted as written
0No fee schedules loaded; no way to identify underpayments
3Systematic underpayment detection; all underpayments appealed within the contractual appeal window
2Large underpayments identified and appealed; small ones written off
1Underpayments rarely identified; occasional appeal when flagged by biller
0Underpayments accepted as paid; no appeal process exists
Score Tally
TOTAL SCORE: _______ / 45
Score Interpretation
36–45 Points
High-Performing Practice (Top 25%)
Estimated annual leakage: 3–7% of collectible revenue ($30,000–$70,000 per $1M in collections). Your fundamentals are strong. Fine-tune denial root cause tracking and benchmark yourself against the top 10% metrics in the 2026 RCM Benchmark Report.
27–35 Points
Average Practice
Estimated annual leakage: 8–15% of collectible revenue ($80,000–$150,000 per $1M in collections). There are clear, specific gaps. Identify your lowest-scoring category and start there. Implementing a claim scrubber and systematic denial rework protocol typically delivers the fastest ROI.
18–26 Points
At-Risk Practice
Estimated annual leakage: 15–25% of collectible revenue ($150,000–$250,000 per $1M in collections). Your revenue cycle has multiple systemic failures. An immediate eligibility and denial management overhaul is warranted. Consider whether your current billing model (in-house or vendor) is equipped to make these changes.
0–17 Points
Critical — Full RCM Audit Recommended
Estimated annual leakage: 25–40%+ of collectible revenue ($250,000–$400,000+ per $1M in collections). Your revenue cycle has critical failures across multiple categories. A full external RCM audit is the recommended next step before making changes — you need a complete baseline, not a partial fix.
What the Leakage Looks Like in Dollars
| Revenue Leak Source | Industry Avg Annual Loss (per $1M collections) | Source |
|---|
| Eligibility-related denials | $27,000–$40,000 | MGMA |
| E/M undercoding / code under-selection | $20,000–$80,000 | MGMA; AAPC |
| Denied claims never reworked (50–65% abandonment) | $30,000–$60,000 | MGMA |
| Commercial payer underpayments (1–3% of NPR) | $10,000–$30,000 | Becker's; MD Clarity |
| Write-offs that were recoverable (AR >120 days) | $15,000–$50,000 | MD Clarity |
| Total average recoverable leakage | $102,000–$260,000 | Composite |
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