To keep the revenue cycle process inhouse or outsource to a vendor—that is the question. At one time or another, most medical practices—especially those that experience growth—come to a crossroads about the best way to manage billing and finances. The decision can get complicated. Suppose, for example, a medical practice has outsourced revenue cycle management (RCM), but is no longer satisfied with the services provided. Now the practice must choose from three options: (1) keep the current RCM vendor and work with them to improve the situation, (2) bring RCM in-house, or (3) switch to a new vendor. When I arrived at Loden Vision Centers in Nashville to serve as CEO, I immediately faced this three-way fork in the road. The practice worked with an outsourced RCM services provider—and had some very troubling financial issues. Processes in both front and back offices were inadequate—especially considering the scope of the practice. Billing practices were poor. Dollars due for major services, including surgeries, weren’t coming in. Also, we weren’t receiving payment for expensive retina drugs. Clinical excellence and high revenue figures hid the consequences of these faults to an extent, but I knew business management couldn’t remain status quo.