Wipfli: Healthcare organizations may be overlooking revenue they've already earned

“A common theme we see across organizations is that they’re not lacking volume, but they’re losing revenue inside their existing workflows,” said Janine Ellingson, healthcare revenue cycle leader, Wipfli.

The opportunity extends across the full revenue cycle. Wipfli advisors recommend that healthcare leaders focus on three connected priorities:

1. Prevent revenue loss before it occurs
2. Protect earned revenue as care moves through the organization
3. Recover cash strategically when revenue becomes stuck

Where are healthcare organizations losing revenue?

Revenue leakage often becomes visible at the back end of the revenue cycle through denials, underpayments and aging receivables. But the underlying issue may have started days or weeks earlier.

Registration errors, missed eligibility checks, incomplete authorizations, documentation gaps, inaccurate charge capture and coding issues can all weaken a claim before it reaches the payer. By the time the problem manifests as a denial or unpaid balance, the organization may already be facing cash delays, staff rework and a lower likelihood of recovery.

In one example shared by Wipfli advisors, a single procedure code was denied 22 times for the same patient because the wrong insurance was billed, resulting in more than $500,000 in denials. The issue could have been prevented through consistent eligibility verification at each visit.

The lesson for healthcare leaders is to look beyond the point where the financial problem becomes visible and identify where the process originally broke down.

How can healthcare organizations reduce preventable denials?

Denials are one of the clearest examples of why prevention can have greater financial impact than downstream recovery.

“The real opportunity isn’t in how we fight denials after they land. It’s in stopping them before they ever happen,” said Valerie Petersen, manager, Wipfli.

According to data discussed during Wipfli’s webinar series, an average hospital denial rate of nearly 12% means that nearly one in eight claims may initially go unpaid. Denied claims also create additional staff work to investigate, correct and resubmit before payment can be collected.

Yet denial prevention is not solely a billing department responsibility. Eligibility, authorization, registration, provider documentation, coding, clinical documentation improvement (CDI) and billing can all influence whether a clean claim ultimately gets paid. That makes visibility and accountability critical.

In one Critical Access Hospital case study, Wipfli advisors identified nearly $4.9 million in denied dollars, with one payer responsible for more than $2.5 million. The issue was not a lack of effort by employees. Instead, accountability for preventing denials was fragmented across departments.

“The challenge wasn’t effort. It was ownership,” the Wipfli team noted during the case study.

Further analysis revealed more than $1.25 million tied to a single preventable denial category. Preventing half of those denials would have recovered approximately $625,000 in revenue and could have eliminated roughly 1,700 claims requiring additional rework. The improvements came through clearer roles, standardized workflows and cross-functional accountability rather than additional resources.

How should healthcare organizations prioritize aging accounts receivable?

Even when revenue has already reached the back end of the cycle, working every outstanding account equally may not be the best use of limited staff capacity.

Healthcare organizations often face competing priorities across aging AR, denials, underpayments and filing deadlines. Wipfli advisors recommend treating AR management as a prioritization strategy rather than simply a volume strategy.

“Busy is not the same as effective,” said Whitney Jacobsen, healthcare revenue cycle advisor, Wipfli.

Instead of asking already stretched teams to work more accounts, organizations can prioritize based on three factors: risk, financial impact and time sensitivity. Filing and appeal deadlines should be protected first, followed by high-dollar accounts, fixable denials and underpayments.

The approach can also help leaders identify patterns behind the backlog.

“If we only work the one account, we may recover one claim. If we identify the root cause, we prevent hundreds of future claims from ending up in the same situation,” Wipfli advisors explained during the AR triage session.

In one example, a three-provider physician group with one biller brought its payment posting current and uncovered approximately $50,000 in underpayments tied to specific procedure codes. The organization recovered approximately $35,000, but the greater benefit came from correcting the underlying fee schedule to prevent the issue from recurring.

Can healthcare organizations improve cash flow without adding staff or technology?

In many cases, meaningful improvement can begin with existing people, processes and technology.

Across the examples reviewed by Wipfli advisors, the common denominator was not adding more work. It was improving visibility into where revenue was at risk, assigning clear ownership and focusing resources on the highest-impact opportunities.

Healthcare leaders can begin by identifying one or two key measures that reveal where cash is getting stuck. Examples include initial denial rate, days in accounts receivable, accounts receivable over 90 days, clean claim rate and net collection rate.

Rather than attempting to improve every metric simultaneously, Wipfli recommends starting with the area furthest from target and using the data to determine where leadership should ask the next question.

For CFOs, the central question is ultimately straightforward.

“Are we getting paid for the care we’re providing?” Ellingson said.

Answering that question requires viewing the revenue cycle as a single connected system rather than a collection of individual billing problems.

By preventing avoidable loss upstream, protecting revenue as care is documented and billed and strategically recovering cash already sitting in AR, healthcare organizations can strengthen financial performance without automatically adding more volume, staff or complexity.

About Wipfli

Wipfli is a leading national advisory and accounting firm with nearly 100 years of serving ambitious middle-market organizations. We understand our clients’ unique challenges and help them succeed on their terms through assurance, tax, advisory, outsourcing and technology services. With 2,900+ associates and global alliances, we combine national capabilities with local relationships. Wipfli operates under an alternative practice structure: Wipfli LLP, a licensed CPA firm, provides attest services, while Wipfli Advisory LLC, a non-CPA firm, delivers business advisory and non-attest services. Learn more at wipfli.com or contact Alicia O’Connell at [email protected].

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Alicia O’Connell
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SOURCE Wipfli