Why the Chief Financial Officer Should Review the Summary Aged Trial Balance Monthly

By Michael Berger, former senior level Revenue Cycle Officer and healthcare finance consultant.

For many healthcare finance leaders, dashboards, KPIs, and predictive analytics have become the primary tools used to assess revenue cycle performance. While these tools provide important operational visibility, one of the most valuable management instruments available to a Chief Financial Officer remains significantly underutilized: the Summary Aged Trial Balance (ATB).

The ATB is far more than a static accounting report. When reviewed consistently and analyzed over time, it provides meaningful insight into cash flow trends, payer behavior, operational bottlenecks, denial patterns, and overall revenue cycle effectiveness.

For CFOs and senior financial leaders, monthly review of the ATB — particularly when paired with quarterly trend analysis — can help identify emerging issues before they materially impact cash flow, net revenue, or operational performance.

Why the ATB Matters

At its core, the Summary Aged Trial Balance provides a consolidated view of accounts receivable aging across the organization. More importantly, it allows financial leaders to identify trends and abnormalities that often signal deeper operational or workflow concerns.

Viewed strategically, the ATB becomes an early warning system for the revenue cycle.

Shifts in aging categories can reveal:

●     billing delays

●     payer reimbursement changes

●     denial management issues

●     underpayment trends

●     workflow inefficiencies

●     staffing performance concerns

●     growing self-pay exposure

While the report itself is static, the interpretation of the data is dynamic. High-performing revenue cycle leaders understand that the ATB is most valuable when used as a trending and management tool rather than simply a month-end reporting exercise.

The Value of Trend Analysis

Monthly review is important, but trend analysis over multiple quarters provides significantly greater insight.

In many cases, meaningful operational issues do not appear immediately. Similarly, corrective actions often require several months before measurable improvement becomes visible.

Quarter-over-quarter comparisons can help leadership identify:

●     accelerating AR growth beyond expected levels

●     deterioration in payer payment patterns

●     rising denial-related aging

●     changes in payer mix

●     increases in self-pay balances

●     abnormal fluctuations in average account balances

●     delays in billing and follow-up activity

Not all increases should automatically be viewed negatively. For example, growth within the 0–30-day aging category may reflect increased patient volumes, improved case mix, or expanded service utilization. However, sustained growth in older aging buckets — particularly beyond 90 days — often warrants operational review.

Operational Example: Identifying Workflow Deficiencies

During a consulting engagement, I reviewed an organization’s ATB and identified unusually high volumes of accounts aged greater than 90 days across nearly all payer categories. At first glance, leadership believed staff were actively managing the balances because account notes reflected ongoing activity.

Further analysis revealed the underlying issue was not a lack of effort, but inconsistent follow-up workflows and inadequate supervisory oversight.

Staff were generating new ATBs each month before fully working prior inventory. Follow-up documentation existed, but resolution activity lacked urgency and accountability.

The organization implemented several operational changes:

●     more aggressive follow-up timelines

●     weekly supervisory review of aged accounts

●     account-level productivity monitoring

●     stricter completion requirements before new inventory distribution

Over a six-month period, the organization experienced:

●     improved staff productivity

●     accelerated account resolution

●     materially improved AR aging performance

The ATB itself did not solve the problem. However, it identified the operational symptoms that led leadership to the root cause.

Key Areas CFOs Should Monitor

Consistent ATB review allows financial leaders to identify important revenue cycle trends, including:

Accounts Receivable Growth
-Growth beyond expected “current” aging levels may indicate collection delays, workflow inefficiencies, or reimbursement challenges.

Billing Delays
-Increases within the 31–60-day aging category often suggest delays in claim submission or initial account processing.

Payer Mix Changes
-Shifts in payer mix frequently become visible through changes in early aging categories and reimbursement timing.

Denials and Payment Pattern Changes
-Growth within older aging buckets may indicate denial management challenges or changing payer reimbursement behavior.

Underpayments and Overpayments
-Significant fluctuations in aging distributions or average account balances may signal reimbursement inaccuracies requiring further analysis.

Self-Pay Exposure
-Increases in patient responsibility balances should prompt review of financial engagement strategies, payment plan structures, and collection workflows.

As high-deductible health plans continue to increase patient financial responsibility, self-pay management remains an increasingly important component of revenue cycle strategy.

In one organization facing growing self-pay aging and deteriorating payment performance, implementation of a recourse financing strategy improved payment plan collection rates from 55% to 94% while also reducing staffing expense associated with account management.

Technology Does Not Replace Operational Discipline

Artificial intelligence, predictive analytics, and automation will continue to transform revenue cycle management. However, even as organizations pursue more advanced technologies, foundational management tools remain critically important.

The Summary Aged Trial Balance is available today. More importantly, it continues to provide financial leaders with actionable operational insight when used consistently and strategically.

For CFOs and revenue cycle executives focused on optimizing cash flow, improving account resolution, and identifying emerging operational risks, regular ATB review remains one of the most effective — and often overlooked — management disciplines in healthcare finance.

About the Author

Michael Berger is a former senior level Revenue Cycle Officer and healthcare finance consultant with more than 35 years of experience in hospital operations and revenue cycle leadership. During his tenure at St. Peter’s Healthcare System, Berger led initiatives focused on improving patient financial engagement while strengthening collection performance and financial stability for the organization. Having worked directly with patient financing programs as both an operator and a client, he now shares insights on revenue cycle strategy, patient financial services, and the financial challenges facing rural hospitals.