Beyond the Metrics: Why Standard Billing KPIs May Be Holding Your Practice Back
Medical billing is crucial to the financial success of any healthcare practice, but are we looking at the wrong metrics? It's hard to deny that healthcare service providers and medical billing companies are still relying on traditional KPIs such as "days in accounts receivable”, “net collection rate”, and “claim denial rates” to measure performance. But wait! Here’s a thought: What if these KPIs - while they are the popular metrics - are keeping your healthcare practice from truly optimizing revenue?
A New Way to Measure Success
Healthcare executives are always told to "track your KPIs," but let’s rethink this approach. Consider these industry-wide statistics:
Are We Measuring What Matters?
Let’s challenge the common myth: "The better you track traditional KPIs, the better your revenue cycle will perform." This narrative often creates a false sense of security. While it’s critical to track data, being overly focused on the wrong metrics can blind you to greater inefficiencies.
1. Days in A/R: Outdated and Overrated
The healthcare industry loves talking about days in accounts receivable (A/R). But here’s the reality— this metric alone doesn't uncover why claims remain unpaid. While a lower A/R is great, solely focusing on this number can mask underlying issues such as incomplete patient information or undertrained billing staff. To address payment delays, digging deeper and tackling the root causes is crucial rather than just chasing a lower A/R figure.
2. Net Collection Rate: A False Comfort
We often praise practices with a high net collection rate (NCR), but NCR can be a misleading metric. Let’s say your practice’s NCR is 95%, which sounds great, right? But this number may obscure issues like small claim write-offs, poor patient collections, or systematic under coding.
3. Denial Rates: The Illusion of Control
Denial rates are another popular KPI, and for a good reason—denials directly impact cash flow. However, managing denial rates alone won’t fix the underlying process issues causing them. Many medical billing companies report a denial rate below the industry average (10-12%), yet they still struggle to keep up with cash flow.
Embrace Predictive Metrics
In the age of AI and automation, it’s time to shift from reactive metrics to predictive analytics. By predicting claim issues before they happen, you can prevent problems and shorten your revenue cycle management process altogether.
Outsource Medical Billing: Efficiency Through Expertise
One of the most strategic moves healthcare providers can make is to outsource medical billing. Medical billing companies, especially those specializing in revenue cycle management in healthcare, often leverage technologies that far exceed what an in-house billing team can achieve. From sophisticated denial management workflows to predictive RCM analytics, these companies have the resources to continuously improve their processes in ways most practices can’t.
Challenge the Status Quo
Here’s the bottom line: Simply following traditional RCM strategies isn’t enough. It’s time for healthcare providers like you to break free from the myth that perfecting traditional billing KPIs will solve your revenue challenges.
Let’s not forget that healthcare's revenue cycle management process isn’t static; it’s dynamic and continuously evolving. By shifting focus from basic KPIs to predictive analytics, deep-dive metrics, and leveraging outsourced expertise, your healthcare company can move from billing efficiency to revenue optimization.
Conclusion: The New Paradigm of Billing Performance
For C-suite leaders in the healthcare space, the future of medical billing lies beyond just crunching the numbers. It’s about seeing KPIs as a part of the bigger picture—an ever-evolving strategy aimed at maximizing every dollar. So, while the industry may continue preaching traditional KPIs, it’s time to shift your mindset and embrace a more proactive, numbers-driven, and unconventional approach to truly optimize your revenue cycle.
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FAQs


ABA providers are grappling with high staff turnover (up to 65%), rising burnout, administrative overload, and stagnant reimbursement rates. These challenges directly impact care continuity, clinical outcomes, and operational performance.


Operational inefficiency costs ABA teams up to 10 hours per staff member per week, contributing to burnout, denied claims, and longer accounts receivable (A/R) cycles. These inefficiencies ultimately result in reduced revenue and patient dissatisfaction.


Burnout leads to costly turnover, lower client retention, and decreased productivity. Recruiting and replacing a BCBA or RBT can cost up to $5,000 per hire, plus months of lost revenue and disruption to morale.


High-performing ABA organizations invest in clear career pathways for BCBAs and RBTs, align compensation with market benchmarks, and foster peer-led mentorship, flexible schedules, and wellness programs.


Automation tools like Plutus Health's Zeus streamline eligibility verification, denial management, and billing, reducing manual workloads by 5–10 hours weekly per clinician and improving clean claim rates by 95%.


Outsourcing revenue cycle management can improve collections, reduce denials by up to 30%, and free clinicians from billing-related admin tasks, resulting in better client care and financial outcomes.


One $200 million ABA network partnered with Plutus Health to automate eligibility and accounts receivable (A/R) processes. The result: $2M reduction in legacy A/R and a 97% Net Collection Rate.


By improving operational efficiency, investing in technology, and ensuring workforce stability, ABA leaders can align outcomes with reimbursement. Plutus Health supports this transition with scalable RCM and automation strategies.
FAQs


ABA therapy billing is the process of submitting claims to insurance or Medicaid for Applied Behavior Analysis services provided to individuals with autism or developmental disorders. It includes using correct CPT codes, proper documentation, and adherence to payer-specific policies.


Common CPT codes for ABA therapy in 2025 include:
- 97151 – Assessment and treatment planning
- 97153 – Direct therapy with the patient
- 97155 – Supervision and modification of behavior plan
- 97156 – Family adaptive training
- Always check with payers for any annual changes.


To bill Medicaid for ABA services, providers must ensure credentialing is complete, services are pre-authorized, and claims use the correct codes and modifiers. Medicaid requirements vary by state, so always follow state-specific billing rules.


Common ABA billing mistakes include:
- Incorrect or missing CPT codesplan
- Lack of documentation or treatment
- Uncredentialed providers rendering services
- Submitting duplicate or late claims


Without proper credentialing, providers can’t get reimbursed. Insurance and Medicaid require that BCBAs, RBTs, and organizations are credentialed and contracted. Delays in credentialing often cause revenue losses and claim rejections.
FAQs


CMS proposes a 2.4% increase in Medicare ASC payment rates, contingent on meeting ASCQR quality reporting requirements. Plutus Health helps ASCs meet these compliance benchmarks by integrating quality reporting data into RCM workflows, ensuring eligibility for full payment updates.


The ASC Covered Procedures List will expand by 547 procedures, including cardiology, spine, and vascular surgeries. Plutus Health supports expansion into new service lines by customizing RCM processes for high-acuity procedures, minimizing claim denials during the transition.


Site-neutrality narrows the payment gap with hospital outpatient departments, enhancing ASCs' cost-efficiency appeal. Plutus Health helps leverage this advantage in payer negotiations by providing performance dashboards and cost-justification analytics to secure stronger reimbursement terms.


Complex procedures increase denial risk and slow cash flow. Plutus Health's automation-first RCM model delivers 95%+ clean claim rates, reduces A/R days, and safeguards margins, even as your case mix becomes more complex.