The $50,000 Line Item and the Cruise Ship: What Waiting Actually Costs

There is something a good doctor and a good consultant have in common, and neither one charges you if they do not find anything worth fixing.

The organizations that figure that out early are the ones that come out ahead, while the ones that do not tend to find out the hard way, usually at a moment when they can least afford the lesson.

The pattern is remarkably consistent. Someone is losing money in a place they have not looked yet, not because they are careless or bad at their job, but because they are busy running the thing, and the assumption that something is "fine" feels a lot cheaper than the time it takes to find out whether it actually is.

The problem is not the loss itself, it is the compounding. Every month an organization waits to look at a problem is a month that problem has already been running, and by the time leadership schedules the conversation, forms the committee, gets aligned, and finally greenlights someone to take a closer look, they have already paid for that delay three or four times over in quietly lost revenue or silently inflated costs.

Think about a cruise ship. It does not turn fast because the physics simply will not allow it, which means the captain who spots something on the horizon needs to make the call early, because by the time that vessel actually responds to the turn, a lot of ocean has already passed under the hull. Early recognition and decisive action might have even saved the Titanic, unless you are a conspiracy theorist, but I digress. A fishing boat is a different story entirely, where you see something, you move, and the decision and the action are almost the same moment.

There is another version of this delay worth naming, and it sounds something like "I do not want to be the guinea pig" or "let's see who else is already doing this first." It feels like caution, and it gets dressed up as due diligence, but what it really does is hand your competitors a head start while you wait for permission from the market to move. To be clear, nobody should be blindly jumping into new opportunities or unproven technologies, and proper due diligence is absolutely part of making a sound decision. But refusing to move forward simply because you would be among the first to do it is not caution, it is a habit, and that habit is exactly what always being second looks like. By the time something is widely adopted enough to feel safe, the organizations that moved early have already captured the advantage, locked in the savings, and moved on to the next opportunity.

Most large organizations are cruise ships, and that is not a criticism, it is just the reality of how they function. Approvals take time, consensus takes time, and implementation takes time, all of which is manageable as long as someone starts the turn early enough.

The organizations that come out ahead are not always the ones that act the fastest. They are the ones that look the earliest.

The math on this is uncomfortable. An organization losing $80,000 a month in insurance underpayments that waits eight months to investigate has not just lost $80,000, it has lost $640,000, and even a successful recovery can never fully close that gap because those months are gone. The ones who avoid that outcome are not smarter or better resourced, they are just willing to look before they have to.

What HEDIS Scores Actually Cost You: The Numbers Nobody Puts on a Slide

Nothing illustrates compounding loss more clearly than what happens when an organization lets its HEDIS scores drift, whether from inattention, delayed intervention, or the assumption that scores are "good enough."

HEDIS feeds directly into the Medicare Advantage Star Rating system that CMS uses to determine bonus payments, and plans with four stars or higher receive a 5% quality bonus applied to their benchmark payment, while plans sitting at 3.5 stars or below receive nothing. That gap is not a rounding error, it is a material, recurring, annual revenue difference that compounds every year the organization fails to close it.

Per KFF, the federal government paid Medicare Advantage insurers roughly $12.8 billion in bonus payments in a recent year, averaging between $374 and $460 per enrollee, and the numbers get uncomfortable fast at different organization sizes.

In 2025, only seven Medicare Advantage plans received an overall five-star rating compared to 38 in 2024, and only 40% of Medicare Advantage prescription drug plans achieved four or five stars, down from 43% the prior year. The bar is rising, the scores are falling industry-wide, and organizations that were not already working on their HEDIS performance two or three years ago are feeling that now in their 2026 payment projections. CMS has also signaled that HEDIS measures will capture nearly one third of the total Star Rating weight going forward, which means the financial stakes tied to these scores are only going to increase.

What Underperforming RCM Is Costing You Right Now

HEDIS scores are one side of the revenue picture. The other is what quietly bleeds out through an underperforming revenue cycle, and the numbers here are just as uncomfortable.

According to MGMA data, practices with optimized RCM achieve net collection rates of 95 to 99%, compared to the 75 to 85% many practices struggle with when managing billing in-house. That 10 to 20 percentage point gap is not an abstraction. On a $10 million practice, it represents $1 to $2 million in annual revenue that was earned and never collected. On a $50 million hospital system, that same gap produces $5 to $10 million in annual losses that show up nowhere on a revenue report because the money was never posted in the first place.

CMS data shows claim denial rates nationally hover around 9 to 15%, while practices using professional billing services consistently achieve denial rates below 5%. The cost of processing and appealing those denials is not free either. MGMA data shows the average cost to collect $100 in revenue ranges from $3.50 to $5.50 for in-house operations, while outsourced RCM providers typically operate at $2.00 to $3.50 per $100 collected.

Most people overlook why in-house RCM underperforms in the first place, and it usually is not the workflow or the software. More than three-quarters of health systems are currently unable to fill essential revenue cycle roles, and the hardest positions to fill are medical coders, billers, schedulers, and authorization staff, which are every role that sits directly between the care a practice delivers and the payment it receives. A vacant or undertrained seat in any one of those positions does not produce a line item on a budget report. It produces aging AR, missed filing deadlines, conservative coding, and denied claims that never get worked. We covered the full scope of that problem in a recent Insights piece, The Staffing Problem That's Quietly Killing Your Billing, and the numbers in it are worth a few minutes of your time if you manage a billing operation of any size.

Every organization should know precisely where its collection rate, denial rate, and cost to collect actually stand. Most do not, and the ones that do are almost always already ahead.

The Fishing Boat Move, Even If You're Running a Cruise Ship

Getting ahead of this does not require a massive internal restructuring or a multi-year overhaul. The organizations that gain ground on Star Ratings, recover underpayments, and improve their revenue cycle performance most effectively are usually the ones that simply agreed to take an early, honest look at where they stood before the urgency of a budget shortfall forced their hand.

That look does not cost anything. What it finds often pays for itself many times over.

If something here resonates, I would welcome the conversation. I am not going to promise a specific number or a guaranteed outcome before I know anything about your situation, but what I can tell you is that if there is something real to find, what we uncover together will be meaningful, measurable, and built to last, not a one-time fix that fades by next quarter.