Like a kid in a candy story, Doctors today have their choice of dental group “flavors”. You have DSOs (the “S” can be support or service, and there is an apparent difference), DPOs, Group Practices, PE backed, VC backed, or even privately held. The great equalizer is that they are all businesses at the end of the day. The only way they continue to operate is by bringing in enough money to cover their expenses, which allows them to invest in more staff, equipment, space, or additional offices. A DSO is a business, all businesses aim to be profitable through effective revenue cycle, thus all DSOs are revenue cycle companies. Revenue cycle management is challenging, but it doesn’t have to be thanks to technology. How is your DSO leveraging technology to improve your business?

Leveraging Technology

Revenue Cycle Management for most DSOs is intertwined and has many feedback loops to previous steps. Offices must deal with both patient and insurance AR, but for this article, we’ll look specifically at insurance AR. For simplicity purposes insurance AR can be broken down into four steps: Verification and Submission, Posting, Claim Follow-up, and Claim Analysis. Each of these steps is laborious and time consuming. There has historically been a lag in the dental industry with adopting technology. However, in the last 5 years the growth of dental groups and DSOs who find themselves requiring efficiency and visibility at scale to be successful has been a driver of change. At the same time there has been an exit of RCM talent in dentistry post-Covid that has driven a boom in the desire and need for technology as a resource multiplier. There are several companies that offer solutions to each of these steps, and some solutions are more straightforward than others. The state of technology in the RCM space is just starting to get off the ground but anticipate big leaps in the coming years.

Insurance Verification/Eligibility of Benefits

The first step in the revenue cycle process is tedious, time consuming, and the data you’re trying to pull isn’t always accurate. The benefit verification process is crucial to effective treatment planning and delivery, as well as informing patients accurately on their payment responsibilities. You need strong processes in place to make sure you’re collecting patient balances before they leave the office because it becomes increasingly difficult to collect once they leave. The process to verify insurance and get a complete breakdown of benefits, for most offices, involves phone calls, faxes, or visiting payor portals. One of the most common solutions to this “people necessary” task is to outsource the work. A third-party company has entire teams dedicated to making these phone calls to insurance companies or getting the data from the payor portals. There are several companies that use technology to help automate these manual steps. Most allow you to set schedules, so you can get the verified patient eligibility and benefit levels a few days before they’re scheduled to come in. These technologies save time by eliminating the looking up of data or encountering miscommunication with an insurance agent. As mentioned before, the providers of this information is a current limiting factor, but it’s slowly getting better through layers of data.


In an ideal situation, you have successfully submitted your claim with all necessary attachments and correct codes. The next step in the payor AR revenue cycle is the posting and closing of claims. Now your office must go through the remittance process and make sure the insurance payment matches the check/EFT/VCC deposit that’s in your bank account. Once you’ve confirmed those numbers match, you then go back to your practice management system to match the potential bulk check portion to the specific claim it belongs to, post the payment, and close the claim. This process requires a lot of back and forth between multiple systems, and additional opportunities for accounting errors to occur. While there is technology available it is a young technology in dental and the automation of posting can become complicated with DSOs with factors like: how they set up their banking structure and legal entities which can lead to additional errors. It’s one of the reasons why there’s such a low adoption of EFTs in dentistry compared to medical. Once the technology can overcome these complexities it will be beneficial in the posting process.

Claim Follow Up

Oftentimes claims are denied or only partially paid because they might be missing supporting documentation, attachments, or codes might be inaccurate for treatment performed. It is even common for there to be a data issue causing denial, or inability of a payor to accept/process the claim on their end. The average office has a Clean Claim Rate of 60%, which are claims that are paid on the first submission without additional intervention from your team. That means that 40% of your total claims submitted need additional attention, which can be a significant amount of collections outstanding. This is revenue that cannot be ignored, so the claim follow up team is usually the largest, both in size and FTE cost for a DSO. These team members log into their PMS, print out an “aged AR report”, go line by line on that sheet to see which patients/claims are still outstanding. Then they have to manually go to each individual payor portal, type in name, date of birth, date of service to try and find the claim. Once they find the claim, they open it, download the EOB, and figure out why the claim was not paid out in full. They have done all the research just to figure out what’s going on, now they still have to go fix the claim data, add the additional x-ray, or attach the requested narrative and go resubmit that claim again. This time inefficiency compounds at scale when there is one person handling 5 offices. Technology, like that provided by InsideDesk, helps to automate the labor intensive and time-consuming part of this process. Team members working aging no longer have to spend time printing out aging reports, visiting nearly as many portals, or making as many phone calls to figure out the status of a claim. The automation of these tasks allows them to close claims faster, get paid sooner, and paid at 100% of what’s owed. While this technology has a proven foundation to be beneficial, it is quickly advancing to provide more data and deeper insight.


The final step in your RCM process should be to analyze your internal processes. The ideal progression is smooth and fast from accurately verifying benefits to cleanly submitting claims, getting claims processed, paid, and posted within a 10–14 day period. While this is a typical timeline for “clean claims”, there are numerous opportunities in this process for things to stall or derail completely. It’s not enough for DSOs to only understand what has happened, but what is currently happening? The reality is it’s extremely difficult to know this today. The data is housed in 2-3 different places, which means pulling in multiple data sources, attempting to centralize, standardize, and manipulate to be able to process through a pivot table. There isn’t an easy way to quickly understand why your claims are being denied, at which offices, for which specific payors. InsideDesk’s analytics provide multiple data connections, which provides a streamlined way of centralizing and presenting actionable data to senior leaders.

The process of getting paid by insurance is simple, but it’s not easy. DSOs are realizing the necessity of technology, as a resource multiplier, as a key part of their RCM solution. They’re starting to understand not only the importance of RCM as a core function, but also that many of the traditional tools don’t provide what they need as they continue to scale. As RCM continues to be an important focus for DSOs looking to scale, the conversations also will evolve into deeper partnerships between dental groups and tech companies to provide the highest value products with scalable functionality.

A Fresh Look at RCM

Revenue Cycle Management (RCM) is gaining momentum like few things have in the dental industry in the last few years. COVID-19, inflation, and an economic slowdown have all contributed to a much higher level of understanding and focus on revenue cycle management in the Dental space. DSOs and dental groups are realizing the importance of this function within their organizations as the primary engine for cash flow and a critical lever to deliver scale. As they are taking a deep dive into their business, most are realizing that they are completely blind to several key performance and operational metrics within their own revenue cycle. To complicate matters, it can often be the case that a DSO maintains and operates more than one flavor of RCM support model at the same time. At scale this becomes hard to keep track of and more groups are finding the value in specialization over generalization of tasks. When it comes to selecting the right RCM model, it does depend on the stage of growth and the nature of the support services that work best with the provider partners.  Perhaps, the right approach is a process, powered by technology and automation, that moves with a DSO over time vs. a one size fits all approach.

One RCM Model to Rule Them All

As DSOs adapt and grow, they are trying to figure out which “model” is the best to use as they structure their teams.  If you keep things In-house, then you’re opting to go through the process of hiring, maintaining staffing, education, and training. You have the ability to manage processes, but how easily can you measure the work being done by 50 employees at 50 different offices? The limiting factor to both in-house models, centralized or decentralized, is people. Skilled RCM workers who can be efficient and effective immediately do not grow on trees. It can take anywhere from 3-6 months minimum for someone to understand all the nuances that go into submitting claims with correct codes and attachments, the best way to work aged claims, or how to expedite your posting and collections process.

The solution for some DSOs and dental groups is to Outsource some, or all of their revenue cycle, to a group that has a team of “experts”. There are dozens of outsourced billing companies that can handle a portion of your revenue cycle, i.e., working aged claims past 90 days, or all of it from verification to posting. While there are plenty of benefits to giving away the headache of making any of the above decisions, it will come at a cost. More importantly, can you verify their effectiveness, or track how efficiently they’re working for you?

 The New “Centralized” RCM Team

Every DSO is faced with the decision of which RCM model they want to build their business on. For some groups it becomes paralysis by analysis as they try to plan long term for their growth, and the cost of pivoting from one model to another seems overwhelming. In the end nothing gets done, nothing changes quickly, and revenue continues to be untraceable with no clear understanding of where improvements are needed.

The best solution might be a “yes” to all models. You’ve probably identified positives from each of the different RCM team structures. As a DSO continues to grow and scale, there are inherently several functions that benefit from “centralization”. The word centralize, as described above, typically brings about a connotation of a team in the same building. While this was true just a few years ago, the age of work-from-home possibility is turning the phrase on its head. Centralization of an RCM team moving forward means we can reimagine the possibilities and combinations. You may have the front office focus on patient intake data entry, patient balances, and claim batching, as they are closest to each of these tasks. Then you might have a team of billers, some working in an office and others working from home, who review and submit claims, follow up and manage claims to Payers, and post payments once processed. This team may focus specifically on claims under 90 days, and their goal is to get insurance payments processed and posted quickly. This ensures that if there is any remaining patient balance, then the office has the highest likelihood of collecting. You might utilize a third-party billing company for any Payer AR over 90 days. These claims might take longer to collect or be associated with difficult/slow Payers where it would be worth the money to let someone else handle and collect your dollars. Ultimately you could mix and match who handles what part of the revenue cycle, but there is a place for each “model” to have an effective place in the entire process. Now the last challenge is how do you centralize a decentralized workforce?

Challenges of “Centralization” and the Necessity of Technology

While the new centralized RCM team is a compilation of multiple teams, this presents obvious challenges for tracking and managing each of the moving pieces. The problem is that today all of the tracking is done manually via Excel, Google Sheets, and in many instances by printing and writing on AR sheets. There are too many moving pieces of data that involve separate software (20 offices on Dentrix, 8 offices on Open Dental, 4 on Eaglesoft, etc.) and reports that must be manually manipulated to figure out what’s going on. You could move everyone to one practice management system, but now you’ve entered a potential change management nightmare. All of this manual work up front to aggregate and manipulate data means that by the time it gets to someone that can make a decision, the data might be weeks or even a month old. Leaders can’t be expected to make effective decisions when the information they have isn’t up to date. The solution? Technology. The new centralized team needs a platform that every team member, regardless of location, can work out of – a tool that provides accurate and transparent reporting that’s easily accessible by all. While most RCM tech is just starting to get off the ground, DSOs utilizing companies like InsideDesk are seeing a 51% increase in RCM team productivity, a 34% increase in AR collection speed, and a $65,000 increase in cash flow per office. These are the measurable increases in efficiency and realized revenue that are possible with the new “centralized” RCM team.

We frequently have conversations with DSOs about revenue cycle performance, metrics, and KPIs. The dental revenue cycle generates mass amounts of useful data which can sometimes seem overwhelming and difficult to organize. However, if you believe the noted management consultant Peter Drucker who said, “You can’t improve what you don’t measure,” then where and how do you start? For any DSO, starting with these five baseline metrics is a great foundation to find simplicity on the other side of complexity. Data is your friend.

Percentage of A/R Greater than 90 Days

Aged receivables exist in every DSO and practice. Calculating the % of receivables over 90 days is an important indicator of the overall health of your RCM because, while some claim failures are inevitable, too high a percentage in the 90 day plus range can be a sign of more systematic and serious resourcing or billing challenges. It’s human nature to deal with the easy claims first, but allowing an unpaid claim to age drastically reduces the chance of receiving any payment at all. Even if the balance is ultimately transferred to the patient, patients will struggle to remember and not feel compelled to pay for a procedure months after a visit. This metric is becoming increasingly more important as out-of-pocket costs rise, so keep a close eye on it.

Ideally, less than 15% of your receivables should reach this age, but the lower the better. The cost to collect increases over time, and the longer you allow your accounts to age, the less likely it is you will recover them and the more it will cost you to do so.

Clean Claim Rate

An ounce of prevention is worth a pound of cure. A clean claim is a claim that flows from submission to collection without needing additional involvement from the RCM team after the first submission. Clean Claim Rate gives your team visibility to problems that are causing claims to require resubmissions, like mistakes in patient registration information or claims failing to meet a payer’s requirements.

They say, “you never have time to do it right, but you always have time to do it over.” Slow down, and focus on clean submissions, clean claims is the #1 way to reduce revenue cycle workload and increase collection speed, the best groups average over 70% in clean claims.

Collection Days

Collecting what is owed entirely and quickly is what all RCM teams aspire to.  Tracking your collection days, the difference between the payment date and date of service, can help you improve your cash flow by identifying and fixing problems in your billing and collections processes that are causing delays in payment. By reducing your collection days you increase the amount of money you collect in a given time period, which can have a significant impact on your overall cash flow. For example, if you are able to reduce your collection days by 10 days and you collect an average of $100,000 per day, you’ve increased your cash flow by $1,000,000.

Ideally, you want to be able to turn over your A/R in less than 30 days. Top performing teams can collect open A/R in less than 15 days though this metric will vary by payer mix as well.

Denial Rate

Your denial rate is the percentage of insurance claims that are fully denied by the payers. There are a couple of possible variations to this metric as it can be calculated both at the claim level but also at the claim line level.  Let’s focus on the claim level. This metric validates the effectiveness of your pre-billing processes, especially your insurance eligibility and benefit validation process. A low denial rate indicates that your revenue cycle processes are working well and you are preventing as many mistakes from happening as possible. Keeping an eye on this metric could alert you to claim pre-billing verification opportunities, submission issues, or sometimes credentialing issues that could dramatically affect your revenue and cash flow.

The best performers have an average claim denial rate below 5%, but many DSOs and practices are regularly over 10%.

Claim Yield

The final baseline metric your practice should be regularly monitoring is Claim Yield. This measure represents what the payer paid against the expected fees.  For example, if your practice collected 70 claims with a total expected amount of $10,000 and received only $6,000 in payer payment, then the claim yield would be 60%.

A high claim yield indicates that the organization is able to successfully collect payment for a large percentage of the claims it submits. On the other hand, a low claim yield may be a sign of problems with the organization’s billing and collections processes, such as incorrect coding, inadequate follow-up on unpaid claims, incorrect fee schedule, or other issues that may be causing claims to be denied. By tracking claim yield and identifying areas for improvement, organizations can optimize their billing and collections processes and increase their overall revenue.

Ideally, every claim you submit for payment would be paid at 100% but we know that isn’t the case. Best practices dictate that your Claim Yield should be greater than 90%, industry best performers can achieve up to 95%.

Starting with a solid understanding of these five key metrics will give you confidence troubleshooting, allocating your time and resources, and put you and your RCM team on a path to continuous improvement.   Monitoring them consistently over time will help ensure that your RCM results are stable, reliable, and hopefully optimized.


The State of Dental

As we head into 2023, DSOs are quickly approaching the crossroads of a perfect storm formed by COVID, The Great Resignation, and a looming recession. How groups handle the next 12-18 months will, in large, determine who comes out on top, and who is swallowed up. The economics driving this shift is due in part to rising inflation and the cost to borrow. Debt is becoming more expensive and riskier for DSOs to continue the explosive growth they’ve experienced over the previous 18 months. A primary vehicle for increasing cash flow has been to add practices to a DSO’s portfolio, but as the winds of change blow, a buzz word floating around the DSO space is “same store growth.”

Recession and Same Store Growth

Same store growth, as it pertains to a dental office, is the primary focus on maximizing efficiencies and increasing cash flow compared to the previous year. There are many aspects of an office to look at to accomplish this: optimizing your supply procurement, utilizing AI to diagnose treatment more often and accurately, and converting more patient calls to appointments. While all aspects of an office should be looked over with a fine-tooth comb, for most offices revenue cycle optimization is the largest source of untapped cash flow.

Importance of RCM

Revenue Cycle Management, RCM, has gained traction from a buzz word to a realized crucial function at the office and DSO level. Anywhere from 60-90% of an office’s patients have some level of dental insurance coverage. This means that most “production” will not be paid by the patient, but that the office will be submitting a claim for insurance payment. The tracking of claims, payments, and outstanding balances due from insurance or patients is the management of an office’s revenue cycle. Unfortunately, this process today is quite manual, time intensive, and difficult to track for a single office. RCM becomes exponentially more difficult when you are dealing with 10 locations, or 50 locations. There are very few tools or reports available within a practice’s management system that allow for the tracking or working of these claims, and it’s made especially difficult when multiple systems are used across an organization (i.e. a few offices on Dentrix, Open Dental, or Eaglesoft). When you look at and understand the steps required to manage and follow up on claims, it’s not surprising that most offices struggle to keep up.

Tools and Solutions

The saying goes, “you can’t manage what you can’t measure.” This is what leaders are thinking, and currently are looking for new technology as an answer. There are companies, like InsideDesk, that are turning the tables, and providing RCM data that finance and operation leaders have been looking for. While the analytics and insights are powerful, it’s only half the solution. InsideDesk also provides a platform to help RCM teams become more effective and efficient, at a time when the cost of labor is at a premium. Automation of tedious tasks like EOB collection and claim statusing allow team members to work more claims per day. The daily guided claims list prevents time wasted from printing out AR reports or creating cumbersome excel sheets. These tools allow offices to increase cash flow, and senior leaders to track progress at a time when “same store growth” is becoming top of mind for all.

The Dental Support Organization world is expanding and evolving constantly. There has been a surge of new groups that have come into the space this year to plant their flag and grow their vision of a DSO. There have also been a handful of large acquisitions, like Mid-Atlantic Dental Partners becoming a part of the Sonrava Health organization; consolidators of individual dental practices consolidating with other DSOs. Dental executives and leaders are realizing that the processes that turn production into realized revenue are becoming more complex and difficult to manage. It takes “a village” of people, often distributed & remote, each accountable for their step in the revenue cycle to ensure success. The more you scale, the more interdependencies and handoffs there are.  Managing a revenue cycle process requires focused leadership.

Revenue cycle teams take on many different shapes and structures depending on the DSO’s business model, personnel, and maturity. The three most common RCM models are centralized, decentralized, and hybrid. These teams are often led by a regional manager, someone in operations, or a more distant finance executive. The leader usually has a list of responsibilities and teams reporting to them outside of the RCM team. Sometimes, they don’t have RCM or claims management specific experience. This is challenging because from the outside looking in, the claims lifecycle seems like it should be straightforward. Anyone doing the job knows that insurance is anything but straightforward. This can create friction when leaders are looking to improve their revenue realization performance, but don’t fully understand why their collections aren’t increasing.

Enter the much needed and necessary revenue cycle leader. This is a vital member to the team that brings claim and revenue specific knowledge. They help to bridge the gap between your frontline employees and your senior leadership. The need for and importance of a designated revenue cycle leader has never been greater than today. They know how to organize the team to optimize for maximum revenue collection. They have the experience to know what to look for in a successful RCM technology solution. Your RCM leader also will understand the importance of visibility on their team’s work to deploy resources effectively. This leader will also know that KPI’s like “90+ days collection” or “revenue realization rate” are going to have the largest impact on increasing collections. These differences produce immediate outcomes that determine whether your team realizes 70% of dollars owed or 95% of dollars owed. Having someone specifically designated to oversee and guide the department that, as mentioned previously, brings in the revenue for the company is an absolute necessity. Most DSO’s have “someone”, but that person needs to be a revenue cycle leader with experience to effectively move the needle. DSO leaders are realizing the importance of this position and should be one of the top priorities going into 2023 if it doesn’t exist in their organization today.