The financial reality for rural hospitals is stark. More than 70% of critical access hospitals are operating at a loss, and nearly half of all rural facilities reported losing money as recently as 2023. For many communities, these are not abstract numbers. When a rural hospital closes, the fallout hits jobs, local economies, and most importantly, patient access to care. These pressures underscore why rural hospital revenue optimization is no longer optional but essential for long-term stability.
In this environment, survival depends less on shiny new technology and more on reclaiming revenue that hospitals have already earned. In a recent Office Hours session, Taylor Searfoss, Vice President of the Acute Care Management Consulting at Infinx, shared practical, low-lift strategies that help rural hospitals uncover “hidden dollars” inside their existing operations—core opportunities often buried within hospital revenue cycle management processes.
The Real Cost of Rural Hospital Losses
The National Rural Health Association has highlighted just how fragile the rural ecosystem has become. Between 2010 and 2021, 136 rural hospitals shut their doors, averaging nearly one closure every month for over a decade. Each closure typically affects one in every twelve jobs in the community and removes a major economic engine, not to mention the only nearby source of emergency and acute care. These closures highlight the ongoing critical access hospital financial challenges that leadership teams must navigate.
These hospitals are often understaffed, under-resourced, and stuck in reactive mode. They do not have large IT budgets, full-time analytics teams, or the luxury of multi-year transformation projects. Any solution has to fit within limited capacity and start delivering value quickly.
What “Hidden Dollars” Really Are
Hidden dollars are not hypothetical gains from new service lines or marketing campaigns. They are real dollars that the hospital has already earned by delivering care but has not been paid for because something broke in the revenue cycle. In other words, they represent hidden revenue in healthcare—income that should already be contributing to the bottom line.
Searfoss described a 25-bed critical access hospital in Montana where his team reviewed 52,000 claims. Thirty-nine percent of them were flagged for review. When the team validated findings against medical records, they uncovered issues such as missed critical care charges, unbilled trauma activations, and infusions that were documented clinically but never properly captured as charges. Cleaning up these gaps produced a revenue lift of more than $2 million without adding staff or changing core systems. The hospital simply started getting paid for the work it was already doing.
Smarter Pricing Without Big-Budget Tools
Strategic pricing can sound like a luxury reserved for large health systems with robust analytics teams, but it does not have to be. Most rural hospitals already have access to the data they need inside their EHR and 835 files.
Searfoss recommends starting with basic utilization and reimbursement data, then simulating prior-year volumes with new rates to see how targeted price adjustments would perform. Sometimes that means raising prices on underpriced, high-demand services. Other times it means lowering prices where you are far above peers and underutilized. Across-the-board price increases leave money on the table and can damage competitiveness. Even modest modeling in a spreadsheet can outperform blunt percentage increases built into payer contracts.
Charge Capture: The Invisible Revenue Leak
Charge capture is one of those areas where many leaders feel confident until the data proves otherwise. Studies suggest that 1.5% to 2% of services go unbilled, which is enormous in a razor-thin margin environment—and this is where charge capture improvement plays a pivotal role.
The problem is often invisible. Services are rendered, documented, and even coded, but never charged. Common culprits include inconsistent documentation, poorly designed EHR prompts, incorrect charge mappings, and staff who assume charges drop automatically when they do not. In one hospital Searfoss worked with, facility critical care charges in the emergency department were missing nearly 100% of the time because of a simple mapping issue.
A structured charge audit process is essential. Retrospective reviews that match billing logs and coded services against expected CPT patterns can flag underrepresented services. Quarterly audits help identify missed charges before timely filing expires. The real payoff, though, comes from moving upstream: standardizing documentation, fixing EHR workflows, improving charge prompts, and training clinicians so the same errors do not recur.
Fixing Root Causes and Using Partners Wisely
Many denial and underpayment issues can be traced back to inconsistent workflows and gaps in knowledge, not bad intent. Comparing like-for-like departments and analyzing charge variances helps pinpoint where documentation, technology, or training is breaking down. Once identified and fixed, these improvements create a sustainable framework instead of endless rework and rebilling.
For resource-constrained hospitals, partnering with an expert can make sense, especially in contingency-based models where the partner is paid only from measurable lift. The right partner should function as an extension of the internal team, provide transparency into their methods, and focus on building internal capability instead of permanent dependency.
One Hour A Week: Where a CFO Should Start
If a rural hospital CFO only has one hour a week to focus on revenue optimization, Searfoss suggests using it where the leverage is highest. Review underbilled or zero-pay encounters and see how many should have generated revenue. Look at your top CPT codes and compare them against volume to spot mismatches that warrant deeper analysis. Most importantly, sit down with your revenue cycle leaders and ask what long-standing issue has never been addressed but they know is costing money. Frontline teams usually know exactly where the hidden dollars are trapped.
Rural hospital survival is not just about cutting costs or chasing growth; it is about systematically claiming every dollar you have already earned in a way that fits your reality. If you are ready to uncover hidden revenue in your pricing, charge capture, and workflows without overwhelming your team, our Infinx experts can help you get started; request a demo if you’re interested.