You Had a Record Month. Your Bank Account Missed the Memo.
A record month can look great on paper while telling an entirely different story in the bank. Controller Sabena Miller explains what IONM practice leaders should look beyond revenue to understand about the financial health of their business.
By Jirah Mickle | September 16, 2026
There are worse problems to have than a record month.
Cases are up. Revenue has climbed. The practice may have finally crossed a number the owner has been working toward for months, maybe years. By most of the obvious measures, business is good.
Then someone looks at the bank account.
For IONM practice owners, the disconnect can be surprisingly difficult to reconcile. If the practice just generated more revenue than ever before, why doesn't it feel like there is more money to work with?
Sabena Miller has spent much of her career helping businesses answer questions like that. Now Controller for Axis Neuromonitoring and Director of Growth Enablement for APEX IONM Solutions, Miller has more than 35 years of experience spanning finance, accounting, operations and business administration. Her career began in consulting and financial systems before eventually taking her into entrepreneurship, healthcare and revenue cycle management. That range has made her particularly interested in what happens behind the numbers.
And when an IONM practice has a record month without the cash to match, there is usually quite a bit happening behind them.
“The biggest misconception I see is that a great revenue month means you had a great cash month,” Miller said. “Revenue tells you what the business earned, while cash tells you what has actually been collected.”
Healthcare makes the distance between those two numbers especially important.
Consider an IONM practice that generates $1 million in revenue during its best month yet. Some of that revenue could still be sitting in accounts receivable while claims move through submission, payer processing, corrections, appeals and collection. During that same period, the practice still has to make payroll, pay physicians, maintain insurance and technology, purchase supplies and cover the everyday costs of keeping the business running.
Growth adds another layer. More cases may require hiring technologists before the additional collections arrive. New contracts can require equipment, technology or administrative support. The practice can spend money today building the capacity required to earn and collect money months from now.
Miller gives the example of that $1 million revenue month producing $600,000 in collections while the business spends $700,000 on operations and growth. Nobody has to be doing anything obviously wrong for the owner to look at the bank balance and wonder what happened. The timing of money coming in and money going out is enough to create the disconnect.
That is why a rising revenue number prompts Miller to start asking more questions. How much of it has actually been collected? How long are those collections taking? What did the practice spend to generate the revenue? What is happening to margins? Are expenses rising faster than cash? What does accounts receivable look like? How much does the business have in reserves?
“Revenue tells me how big you’re getting,” she said. “Cash flow and profitability tell me whether you can afford to keep growing.”
When growth starts eating cash
For a practice owner, that distinction becomes more consequential as the business gets bigger.
Revenue is an easy number to celebrate because growth is visible there first. More cases produce more revenue. New contracts produce more revenue. Expansion produces more revenue. The costs and collection delays attached to that growth are scattered elsewhere across the business, which can make them easier to overlook until cash starts getting tight.
Miller has seen businesses get caught in that gap before. “You can grow yourself right into a cash problem,” she said.
An IONM practice could be performing more cases every month while its accounts receivable ages. It could add revenue while margins shrink because the cost of supporting those cases has increased. It could make investments based on revenue it has earned but won't collect for another several months. Individually, those changes may not look alarming. Together, they can leave a growing practice with less financial flexibility than its revenue suggests.
This is also where Miller's experience in revenue cycle management changes how she reads a financial statement. She tends to trace financial changes back through the business to understand where they began.
A cash problem, for example, may have started several months earlier as a documentation problem.
A rise in denials could come from authorization, coding or credentialing issues. Claims may simply not be getting worked quickly enough. Cases continue to be performed, so the practice continues recording revenue, but collections begin to slow. Accounts receivable gets older while payroll and other operating expenses continue arriving on schedule.
Eventually, the practice may begin using reserves to cover routine expenses or postponing investments it had planned to make. By the time the problem becomes obvious in the bank account, its origin may be sitting much farther upstream in the revenue cycle.
“That’s why I see RCM as more than billing,” Miller said. “It’s part of the financial health of the business.”
What can the business actually afford to do?
The consequences become particularly real when an owner has a decision to make.
Suppose the practice has an opportunity to hire someone who could support additional growth. A healthy bank balance might make the decision seem easy. A low balance might make the owner hesitate. Miller argues that neither number, on its own, provides enough information.
An owner who understands the practice's cash flow, collection trends, upcoming obligations and reserves can evaluate whether the business can carry that employee through normal fluctuations in collections. Without that visibility, the practice risks hiring faster than its cash can support or becoming so cautious that it passes on an opportunity it could have afforded.
“Financial visibility doesn’t eliminate risk,” Miller said. “It gives you the information to take the right risks at the right time.”
The same thinking applies when the stakes get bigger. Before expanding into another market or making a significant investment, Miller wants to know whether the business can sustain the decision under less-than-perfect conditions.
That involves examining cash flow, profitability, reserves and collections, along with the cost of growth already underway. For larger investments, she may also evaluate expected return, payback period, Net Present Value and Internal Rate of Return. Then she changes the assumptions. What happens if revenue falls short of the projection? What if costs come in higher? What if the return takes longer than planned?
A practice may have enough money to make an investment and still lack enough financial room to comfortably absorb what happens afterward. That difference matters when reimbursement can already be unpredictable.
Your dashboard isn't the answer, either
Better financial visibility might sound like a case for more reporting. Miller is careful about that assumption.
Healthcare businesses have no shortage of numbers available to them. A practice can track revenue, collections, accounts receivable, denial rates, margins, days sales outstanding, expenses, forecasts and dozens of other measures. Add enough dashboards and it is possible to know almost everything that happened without having a particularly clear idea of what to do about it.
“More data doesn’t necessarily mean more visibility,” Miller said. “You can have pages of reports and still not know what’s actually happening in your business.”
She prefers a smaller set of questions that force the numbers into context. Is the practice profitable? Is it collecting what it earns? Where is cash going? Are margins improving or shrinking? Is performance tracking with the forecast, and when it isn't, does leadership understand why?
Trends matter here, too. A record month can be meaningful without proving that the business is financially healthy, just as one disappointing month doesn't necessarily signal trouble. Seeing what is changing over time, and understanding what is driving the change, gives an owner far more information than a single headline number.
“If the data isn’t helping you make a decision, it may just be data, not insight,” Miller said.
The record month is only part of the story
That brings the record month back into perspective.
The revenue number still matters. An IONM practice should know when it is growing and celebrate the milestones that come with it. But the more useful conversation begins after someone asks where that revenue went.
Maybe it is waiting in accounts receivable. Maybe collections are taking longer than expected. Maybe the practice has been investing heavily in the people and infrastructure required to support its growth. Maybe margins have changed. Or maybe the question uncovers a revenue cycle issue that has been affecting cash for months.
Finding out requires following the money through the business rather than stopping at the number at the top of the income statement.
Miller summed up the idea more simply when we asked her to finish one sentence:
A growing business should worry less about how big it looks and pay more attention to how financially healthy it is.
— Sabena Miller
A record month tells you the practice is producing more. Understanding what happened to the money tells you whether the business can keep doing it.
About Sabena Miller
Sabena Miller is an accomplished finance and operations leader with more than 35 years of experience helping organizations strengthen financial performance, improve operations, and build for sustainable growth. Her career spans financial systems consulting for organizations including the New York Stock Exchange and First Data, entrepreneurship, business strategy, and healthcare revenue cycle management. A former business owner with more than 15 years of firsthand operational leadership experience, Miller currently serves as Controller and Director of Growth Enablement for Axis Neuromonitoring and APEX IONM Solutions, where she brings a practical, cross-functional perspective to finance, strategy, and organizational growth.
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