Hamza Asumah, MD, MBA, MPH
Most growth conversations in a dental group start in the same place: how do we get more patients, more providers, more chairs, more days. It is the instinct of every operator I know, myself included, and it is expensive.
Here is a number that should change where that conversation starts.
For a group generating $10 million in gross production, closing the average gap between what is produced and what actually reaches the bank adds roughly $890,000 in annual EBITDA — without one additional patient, one additional provider, or one additional operatory. That figure comes from Planet DDS’s 2026 DSO Outlook, drawn from a dataset covering 477 DSOs and $6.83 billion in gross production.
Read it again. That is not a growth number. That is a collection number. The work has already been done. The chair time has already been spent. The team has already been paid. The only thing that failed is the process between the treatment and the deposit.
The five stages nobody maps
Every dollar of gross production passes through a sequence before it becomes cash, and most groups only measure the first stage and the last one.
Gross production is the value of care delivered at full fee.
Contractual adjustments come off first — the difference between your fee and what the payer contract allows. Largely fixed by contracts you signed, but not entirely; more on that below.
Net production is what remains: what you are actually entitled to collect.
Patient portion versus insurance portion splits next. The insurance side moves through claims. The patient side is supposed to be collected at the chair.
Cash collected is what lands.
The leak happens in two specific places, and the industry data is unusually clear about which ones.
The first is time-of-service collection. The median net collection rate across the dataset sits at 88.9%. Median over-the-counter collection is 91.3%, but the mean is 87.9% — that spread between median and mean is the tell. It means a meaningful tail of practices is dramatically worse than typical, and the residual represents patient copay balances simply not collected while the patient was standing in front of you.
The second is aged accounts receivable. Estimates put AR over 90 days at around 55% of total AR in the average group. Once a dental balance passes 90 days, the probability of collecting it falls off sharply. It does not disappear from your books; it just stops being money.
Why this stays invisible
Because none of it touches the top line.
A location can post excellent production, hit its budget, look strong on every report presented in a monthly meeting, and quietly lose six figures a year in the gap between production and cash. Nobody gets called into an office about it. There is no dramatic month. It is a slow, structural leak that shows up in margin without ever showing up in growth.
And the incentive structures make it worse. Most bonus programs, most doctor compensation, and most manager scorecards are built on production. Very few are built on net collection rate. So the organization measures the thing that is fine and ignores the thing that is broken.
There is a second reason it hides. Responsibility for the gap is split across three groups who do not sit together: the front desk collects the patient portion, the billing team works the claims, and operations owns the schedule. Each can be doing their job competently while the handoffs between them fail.
What to actually do
Calculate your real net collection rate. Not gross-basis collection — that figure is misleading and should not be benchmarked. The correct metric is net-adjusted collections against net production. If you are below 95%, you have a recoverable gap. If you are near 89%, you are at the industry median, which is to say you are losing what everyone else is losing.
Separate the gap into its two components. How much of your shortfall is contractual adjustment, and how much is uncollected patient portion? These have completely different fixes. Contractual write-off is a payer negotiation problem. Uncollected patient portion is a front-desk behavior problem. Groups routinely conflate them and then apply the wrong remedy.
Age your AR and be honest about the over-90 bucket. Then ask the harder question: what percentage of that aged balance was a patient portion that should have been collected at the chair on the day of service? That number tells you whether you have a billing problem or a collection-at-the-chair problem.
Audit one week of appointments at one location. Pull every completed appointment with a patient balance and check whether the balance was collected that day, collected later, or still outstanding. One week, one location, about two hours of work. It will tell you more than a quarter of dashboards.
Monday morning
- Ask your billing lead for one number: net-adjusted collections divided by net production, trailing twelve months, by location. Not gross-basis. If nobody can produce it by Friday, that is itself the finding.
- Pull the AR aging by location and calculate what percentage sits beyond 90 days. Rank your locations. The spread between your best and worst will be larger than you expect, and the worst location is where you start.
- Run the one-week appointment audit described above at your lowest-performing location. Look at what happened at the front desk on the appointments where nothing was collected. In most cases you will find no script, no policy, and no expectation — not defiance.
- Add net collection rate to whatever report your practice managers see weekly. Not monthly. The behavior you are trying to change happens daily, and a monthly number arrives too late to correct it.
- Before your next leadership meeting, calculate what closing half your collection gap would be worth in your organization. Take your gross production, apply your current shortfall against a 95% target, halve it. That is the number that gets a revenue-cycle project funded when a general efficiency argument would not.
The reframe
Growth is expensive, slow, and uncertain. You market, you hire, you wait six months to find out whether it worked.
Collections are none of those things. The patients already came. The dentistry already happened. The margin on recovered collections is close to 100%, because every cost associated with producing that revenue has already been incurred.
If you are running a group in 2026 with flat production and rising overhead — which is most groups — the highest-return project available to you is not a new location. It is finding out exactly where your money stops moving.
Sources: Planet DDS, 2026 Dental Industry Outlook Deep Dive (477 DSOs, $6.83B gross production; median NCR 88.9%; OTC median 91.3%, mean 87.9%; AR >90 days ~55% estimated); Dental Economics–Levin Group Annual Practice Survey.
Dr. Hamza Asumah 
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