Unlocking Solutions: Benchmarking Within Your Own Walls

Published in Member Communities on July 02, 2025

By Ronda Buhrmester, Senior Director, Payer Relations, VGM & Associates and Kim Cuce’, Director, Business Optimization, VGM & Associates

The song by the O’Jays that has the lyrics “Money, money, money, MONEY!” is commonly on repeat in our brain. If you know the song, what is the name of the song? This is not about being greedy; we all want to do good things. We need the cash to sustain a financially nourished business. In our industry, we tend to think of the patient first and business second or even last. That is okay, and it’s important. However, maybe there is a way to find the balance of both being at the forefront. Truthfully, in most industries and most companies, it’s common to have areas of financial losses. In our industry, the financial loss has grown too high. We seem to not stand up enough for our own business because of a payer making a statement that makes us feel obligated, or wanting to please a referral because we don’t want to upset them, or maybe due to competition. We find that money is being left on the table with missed revenue opportunities. You all would agree with that statement. Where do we start? We don’t know what we don’t know.

We start by uncovering the root cause of failure to reveal the root cause of success. Has your company ever looked into or considered benchmarking within your own walls? The industry tends to want that benchmark for comparison to other companies, and that is not a bad idea. Looking within your own walls has even more substance because it takes into account the products, payers, size of company, and volume of referrals, all being individualized within your own walls.

When striving for excellence, focus on internal metrics and standards. Measure performance against your company’s historical data and achievements. While industry benchmarks matter, continuous improvement comes from exceeding your own past performance. Implement a strategy to identify cost reduction opportunities, explore untapped revenue streams, and achieve operational excellence by addressing root causes.

Common areas that are benchmarked are DSO, held revenue, denial rates, and accounts receivable. Taking a quick glance at those metrics indicates how well a company is performing financially. This is where the monitoring and performance can be viewed and dialed into the root cause.

The mother of all root causes is system setup and system maintenance. We often ask how the price tables are being managed. These can make or break a business. These are not a “set it and forget it.” Price tables affect the entire cycle of starting with that initial referral and initial order to claim submission and payment.

Begin “training up” from the start of the order. Customer service (front office) should have all the tools for knowing the variety of payer coverage criteria, qualifying a patient from the beginning, and knowing when it’ s not covered. Customer service should easily be able to know when a prior authorization is required and be able to explain the financial obligations to the patient. Training up can decrease the DSO, decrease denials, and even decrease patient complaints.

When process mapping, questions that need answers are how many staff touch an order, who requests CMNs, is a CMN necessary if there is a valid SWO, who is logging the CMN, and who is confirming the CMN? Training up and giving the customer service team the confidence will empower the individual to be well rounded with their role.

If you were to review the held revenue report, the most common reasons seen will be CMN missing, CMN expired, prior authorization missing, prior authorization expired, and manual held. These are hands down the most common reasons we see with companies, or it’s being stopped because of (guess what?) price table issues.

Let’s look at splitting up the stop/hold report to work more effectively. Looking at the price tables, ask if there are multiple options or too many options, the table wasn’t updated, policy expired, HCPCS code issue, or policy ineligible. Managing price tables should be assigned to someone to keep these errors at a minimum. Pending pick-up work orders tend to be another common issue. Let’s make these more of a priority to allow for confirmation to run smoother, easier, and quicker.

When looking at denials and ones that can be avoidable, there are probably several. One common avoidable denial that can drive many of us crazy is timely filing. We all need to understand the payers we work with and know their timely filing limits. A payer like traditional Medicare has 12 months for timely filing, which is very generous. Many other payers provide less time, as some are only six months. There is no reason for a large or significant volume in the timely filing bucket. This is super easy to fix. Review the payer contracts for the timely filing limits, train staff up, and set up the system to recognize this information. The other common area of denials that hits a large bucket is no prior authorization obtained. Know your payers in detail, set up the system correctly, notify when a prior authorization is required, and train up!

Lastly, looking at accounts receivable (A/R) buckets. This tends to get eyes rolling because of the research and time involved. Guess what? Keeping the denial rates lower and system set up correctly will play a huge role in keeping the A/R in a good position. The eyes will stop rolling, and that is a guarantee!

When a DME company focuses on benchmarking within their own walls, the continuous improvement then lies in surpassing one’s own past performance. 

The tables will not have money left behind. It all starts with accepting change. Not accepting change will result in continuing to leave money on the table. Change is hard at first, messy in the middle, and gorgeous at the end. For the love of Money, money, money, MONEY! 

Reach out to rcs@vgm.com learn more about benchmarking (measuring) within your own walls.

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This article was originally featured in the VGM Playbook: Cost Management Trends, Strategies, and Solutions. To read the full article and more like this, download your copy of the playbook today! 

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