#179 Building a Practice That Runs Without You - The 5 Systems You Need

Most physician owners we talk to took a vacation last year and spent half of it answering billing questions on their phone. That is not a staffing problem. That is a systems problem. 

In this episode, Dr. Heather Signorelli walks through the five operational and financial systems that allow a practice to generate and protect revenue without the owner acting as the lead biller, the collections manager, and the operations director all at once. 

You will learn: 

• How to take clinical knowledge out of one doctor's head and turn it into practice-wide standards 
• How to get daily financial visibility without waiting 30 days for a CPA report 
• How software hard-stops protect revenue even when your best staff member quits 
• How to benchmark provider productivity without having awkward conversations 
• How to give managers real decision-making authority without losing control of your margins 

📊 Free Practice Revenue Leak Scorecard (takes 3 minutes, free): 

eligibility.natrevmd.com/nrm-revenue-scorecard-v3 

📅 Book a free 30-min call: 

calendly.com/heather-natrevmd 

Transcript

SPEAKER_00 0:04

Most physician owners we talked to took a vacation last year, but they spent half of their time answering questions on their phone, checking in on staff, solving problems, and answering emails. Obviously, if this sounds like you, you walk away feeling burnt out, even if you've had time away. And this isn't a staffing problem, but a systems problem. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. So when your practice is requiring your daily attention to catch patient questions, staff call-outs, questions on denials, maybe issues with billing or proving simple things like write-offs, or even trying to keep cash flow stable, or being the one who needs to see all the patients in order for the revenue to come in, you have built a job, not a business. And today we're going to talk all about how to systematize your business so that you can have time away, get a chance to regroup without feeling like everything's going to fall apart. So obviously, the moment you step back, even for two weeks, if cracks are appearing, um, that's the time to look and think, okay, what cracks appeared? What do I need to fix and go through? So this episode is for practices with multiple physicians, multiple providers, a billing team, um, and really, you know, a group of individuals who help already run your practice. Obviously, I know there's micropractices out there, and you may be the only person. And obviously, some of these are going to help make sure that you're building a practice for the long run that isn't always dependent on your brain. But really, those, you know, multiple location or facilities with five, 10 providers and a team of individuals, whether that's front office, office manager, back office. But at that stage, the question is not really are your people working hard enough? It's a question about whether or not the systems you built are well enough to run without you in the room. So by the end of this episode, you will know the five systems you need to build so that your practice scales, revenue, whether you are there or not. And essentially, here's the core idea, right? So every practice often relies on the owner to generate every dollar and approve every decision. And that's not scalable. And while a business may start out that way, especially in that single physician or single doc practice, but if you are trying to move beyond that and you're scaling beyond yourself, you must shift your thought process away from managing people or just managing people to managing systems and then let the systems manage the people across your clinical operations and financial departments. All right. So we're going to talk about the five systems. Before we do, we do have a revenue scorecard that you can check out and run and see if you so if you do want to know where your revenue cycle is already leaking before you build any of these systems, want you to check out we have a free practice revenue scorecard. It takes a few minutes, literally tells you where some of those gaps are. You can check out the link down in the show notes. So I am very excited about this podcast because for me as a pathologist, you guys know I love a good policy and procedure. You guys already, if you've been listening to us for a long time, know I love a good spreadsheet. And really being able to understand the framework that you've built in the office in each of the different segments of your practice is really, really key. And I like to think of these in buckets, right? So if you think about your practice, I think mapping out all of the different sections within your practice that matter, right? So we've got the front office staff, right? What tasks are they responsible for? You've got your clinical team, your nurses, your MAs, you know, the process around bringing a patient back, getting their vitals, having a physician team or provider team see those patients and that workflow. Then you've got the back office workflow around submitting those claims, getting that information to the insurance payers, cleaning up any accounts receivables, getting outpatient statements, you know, all that back office stuff. And then, depending on the size of your company, you know, the marketing or approach to capturing those patients or increasing volume, whether that's marketing through a third party or that's referrals or a combination of all of those. I think all of those are different buckets within a practice. And so the first thing that is really, really important as you think about your practice is standardized clinical protocols. I love a good policy and procedure. And for our business, this is really, really critical. Everything from how we onboard clients, the checklists for that, how we create our own policies and procedures for each of the practices, how we audit, how we hold our billing staff accountable, how we hold our managers accountable, how we do end of month metric dashboards, all of these things impact the business on our end. And the more we have that standardized, the easier it is to hold staff accountable, the easier it is for our team to manage the number of accounts we have and have the same high quality regardless of the individual that's on the account or the size of the account. And I think that's really important when you think about standardized clinical protocols. It's because you're taking the knowledge out of your best and brightest staff members, or you're bringing together different people's strengths and skill sets and putting them into one place. What one staff member may be good at, another staff member may struggle with, but they may have a skill set that the other one doesn't. And so you're, as you build your practice in your business, you're taking all of that information both within your own head, your rock star staff members, your people who've been there for a very long time, and you're compiling that into one location. And you're you're creating it in a way that allows somebody who's new to the practice to pick it up and go, step one, I do this, step two, I do this, and go all the way through from start to finish. And then at the bottom, understanding how who does this, how fast do they do it, how often do we measure the success of this, and you put that into a policy and procedure. And you actually today is the best time in history. If you don't like doing this, you don't have to necessarily do all of this yourself because there's AI tools all over the place to be able to accomplish this. And you will not be able to scale patient volume and provider volume and staff without being able to manage this because there's unpredictable things that happen in every single visit, in every single patient encounter. And so if you're able to give the rules by which, in general, people should adhere to, you're then going to be able to lead your office with the same level of quality no matter what, and without you having to necessarily make all of those things happen. And that's the biggest thing I see with the difference between our smaller practices and our larger practices. And even the difference between where we are now versus where we were four years ago is the ability to create a system out of what is working. And obviously, this is this is something that changes. Obviously, you don't want to change it so much that you're making your staff dizzy, but it changes in a sense of where you were two years ago may not be where you are today. And so you do have to re-look at these things, but it allows your team to instead guess of what they're supposed to be doing or what they're supposed to be ordering or how they're supposed to be doing an intake or when they're supposed to be uh completing their charts or how often they're supposed to be submitting claims. You put all of that into a standard. And that standard then guides people. But you put those guardrails within the policy to a degree, or you set a group of individuals who's responsible for that, for those issues that come up or those last-minute things that come up, without it always having to be you, the owner of the practice. And then that way, when you do decide to go take a vacation and you do decide to disconnect, there's somebody there who knows how to manage those situations. So obviously, why this matters, you want to be able to have a system that gives you clear visibility, control over the clinical quality processes in your office and even the financial ones, but regardless of who shows up that day from a working perspective. And so without it, you're gonna struggle with, you know, your rock stars doing a really good job, but maybe new staff struggling to understand what they should be doing or how they should be doing it. And maybe they catch up and they're also rock stars, but that may be six months of training instead of, you know, one month in training in terms of what does it, what does good look like? And that's what I really want you to sit down and think about. And so I think from a steps perspective, first really sit down and go, okay, what are the departments or segments within my office? Right. And so I kind of talked front desk, back office, you know, the clinical team, your provider team, uh, marketing, for example. I put those buckets again, that may make sense for you, make be thinking, okay, yeah, that that I get that. Or you may be thinking, well, I, you know, I have, you know, a pediatric side and an internal medicine side, or, you know, I do infusions in the office, or I have a hospital team and a clinic team. And that's fine. But I want you to jot those things down and then going through each section individually. Pick the one that gives you the most headache. Pick the one that's bugging you the most for decisions and start there. Start by really outlining, okay, step one, step two, step three, you know, where, where does it start and where does it end in terms of that process, and then walking through each of each of those steps of what good looks like. And then obviously you're wanting to understand who's responsible for that, what is the timeliness or the timeline for that. And then just jot all that down in a Word document and then throw that into Claude or Manis or whoever you're using. I don't find Chat GBT to be really good at this, but I right now I'm really liking Claude for this. Put all of that together so that you can really map out exactly step by step what it is that good looks like, and then get feedback from your staff, right? Does this make sense? Did I need to change this? Have an iterative moment, put it into use as a pilot, have people use it for training, analyzing how their day went or did they get everything done? And then once it's final, you could even take those and put those into checklists for training for complicated or highly repetitive tasks. That's another way that you can use as a tool. Um, so you could have a front desk tracker or a checklist, right? So that's all the things that they need to do on a daily basis or weekly basis. And that's sitting as a job aid at the front desk, laminated, that they can go, okay, yeah, I did all those. Or that can be used as a tool for somebody who's brand new that they can actually physically check those things off until they get into a rhythm. So, really, really important, if you are wanting to run a practice where you don't have to make all of these decisions, this needs to be a critical part of them. All right, so number two is automated financial visibility, which we talked about a couple episodes ago. If you haven't checked that out, go check that episode out where we talk about building dashboards. And these dashboards are going to track your key metrics without you asking for them. And that can be somebody pulling those reports for you and putting them into a dashboard. These dashboards can be something like what I described using an AI tool or a website. Um, these can be simple like a Google uh Google Sheet, which is what we use for our metrics coming from practice management softwares to look at end-of-month billing metrics. This doesn't need to be fancy, but it does need to be simple, right? What are you tracking and why are you tracking it? And then if you have something that's out of metrics, what are you doing about it to get it back into line? And so obviously you can't make decisions about hiring, expansion, marketing, uh, et cetera, if you are struggling to get reports or metrics that you understand. And this can be everything from revenue, from billing metrics to expense metrics, because you'll want to compile all of that into one view. And so obviously, if your billing team's giving you, you know, one way, download that report and then use that to understand, you know, at your expenses that's coming from your CPA, you should be able to have that as an automated mechanism that you can get all of that information and have a dashboard pulled together so that you can always have what you need in order to make the decisions that you need. And I think another big piece of this is are you the only person who can sign off on invoices, who can sign off on payroll? All of those things should become systems as you grow. Obviously, when you're small, you may be the one who's doing all of that or signing off on all of that as you get bigger. You may be hiring individuals to help take that on. And so again, what is your process? How often is it done? Who needs to do it, et cetera, is gonna be really, really, really important. Obviously, why this matters, a system that you can repeatedly produce and that is operating automatically without you having to make a decision to ask for it is really, really key. So if everybody knows, hey, we're gonna pull these metrics, we're gonna display it this way, we're gonna do it on this date, and these are the inputs that are coming from it, that's gonna be the best way for you to be able to make those decisions when you do need to make those decisions. And then as this evolves, right, you may be making 10 decisions, you know, a week when it comes to this type of information. But as you delegate those things to an office manager or to a, you know, a fractional CFO or even a full-time CFO or controller, then those things start to get on their plate with your framework in mind as the owner. But then that framework then becomes a standard policy and procedure. So you can kind of see how this builds, right? Um, it's really all about standardization. It's about metrics and dashboards. And again, I'm a big believer of don't measure it if you're not gonna do anything about it, or don't measure it if it's got some sort of data integrity because everybody's just gonna go, that that metric, it's never accurate. Just take it off until you can focus on it and figure out if that's a metric worth fixing. And then once you fix it, then it can be something you monitor. All right, so the third section here really goes back to specifics around operations for your billing team. Obviously, the standard policies and procedures are really important for all sections, but I'm gonna focus a little bit right now on how you operationalize the billing rules to make sure that there are processes in line for your billing team. And this is most critical for an in-house billing team. Obviously, if you now have an outsourced billing team, you want to understand how they work and how they operate. So I'll share with you a little bit of how we do our process. So we obviously have an onboarding checklist and that has evolved over the years. We have an onboarding policy and procedure in terms of how we get this done. We're also taking those onboarding um uh checklists and putting them, putting them into a project management software to check off that those are all being done as we go. And again, this has been an evolution for us as well. And so for you, you're gonna want to have that same process if you do have an in-house team that that you have that for new staff members, for uh making sure that anybody who comes onto your team knows how to do this. Now, if you are struggling because you don't really have a billing leader, right? You have multiple people who are doing billing, but they're doing them in silos or with a lack of strategic oversight. That's the biggest risk that I see in in-house billing teams is really somebody who is sitting and it's oftentimes, you know, can be an office manager depending on their skill set, or if they're busy doing other things, that might not be what they can give their time and attention to. And so if that is a struggle, it may be worth looking and seeing, okay, how is that process working today? What are some of the pros of having that in-house team, or do I need to consider other options? So, from a billing uh protocol process, right? So we all know that billing starts at the front desk. And so if you have your front desk down in terms of eligibility and prior offs and patient collections, that's only going to help prepare your billing team on the back office. And you want to make sure that you have the policies together for that front office piece and then also for the back office. How quickly are they sending claims out? How quickly are they payment posting? How do they hold people accountable for AR follow-up? Who's auditing that AR follow-up? How often are they touching those claims? All of these things become incredibly important for you to make sure that somebody has an oversight. And so where we see practices struggle is they have silos where somebody's doing the claim, somebody's doing the payment posting, but nobody's really monitoring and managing those individuals other than did they show up to work today and does revenue look okay, right? You obviously know when revenue goes up and down, but what's really happening behind the scenes is really, really, really important. And so instead of just like hoping that these people do the right things, you want to make sure that you have a system in place, both in your practice management software, also in your policies and procedures that steps out all of this information, right? So when should they be doing eligibilities? How often should be submitting claims? Um, what happens when they uh see a deposit come in, but we don't have an ERA, ERA or EOB? Who are they going to and how is that being tracked and monitored? So for us, we have this all written down, both in a template policy that we use for practices, but then we add the practice-specific information so that every detail is there. And I would say over the years, this has become more detailed. We even for our newer practices are even starting to record videos of these processes so that if any new staff member needs to be changed, or if we have a new hire or we have a turnover, that those individuals, when the new hires come on, they read the policy, they've got the videos, et cetera, they've got checklists. And I know that some of you guys may be thinking, goodness, this is a lot of work. And I would say yes, but I think for larger practices, for more complicated multi-site locations, the standardization is what allows you to have the same level of quality and the same level of net collections or collection rate success, I guess I would say, so that everybody, really no matter who's sitting in the seat, is doing the same job the same way. With this, software is really important here. And I know I've talked about this before, but want to bring this into context here because your software, if it's not behaving the way you want it to, can create in a lot of workarounds. We see that with some of our Tibra practices, because Tibra just doesn't have as many features as others. And so then you're having to have workarounds. And so obviously capturing those workarounds in policies and procedures is important. But then really doing a deep dive, is this really the software for your growing practice? Um, when you're smaller, maybe that was sufficient, but if as you've grown, that may not be. And so, really important for you to understand and put this all into the policy and procedure, look at how those software functions work together, and then write out those steps for your billing team specifically. And so this includes not only just your expectations, right? So that's how SUNA claim gets submitted, how sumo payment gets posted, but then the operations of how you work it in the system and then how you hold each other accountable. For us, we use a lot of trackers, I shouldn't say a lot, a handful of trackers that allow us to track and hold these things accountable. When we can leverage the EMR system and the PM software for that, great. And we are working on some automated tools to figure out how to automate those things so that we take away that manual work. But again, the end of the day is you really, really want to make sure that these expectations are clear and the steps are clear. And so we have actually built for groups these processes within the EMRs so that you can make sure that you have the right stop gaps, you have the right reports coming through, you have the right coding rules. And so, really, really critical that the software is supporting your process and your process is supported by the software. All right. So, last thing that I think is really, really important for again, putting yourself in the framework of I'm going to step away. I am not the only decider in this business. And I have a team of people who are there to help me succeed is provider productivity benchmarking. And obviously, this requires a very transparent, objective financial and clinical standard for your group. So it's really about understanding what is your overhead, what are your expenses, what is your revenue that's coming in, and getting together those provider level benchmarks of how many patients does somebody need to see in order to cover their share of overhead, to cover, you know, their own salary, and then to hopefully have profit left over at the end. Obviously, you can't scale if you are subsidizing underperforming physicians or if people aren't signing out their charts. Um, and so you want to detail out, okay, what are the expectations for these roles ideally before you hire them? And then what does good look like and how long do you expect them to ramp up to what good looks like and then be able to provide them a bonus or an incentive for hitting those metrics because then it aligns everybody to the same goal. And so having a productivity, you know, dashboard or metrics could be another part of your financial metrics, right? So you've got revenue, you've got billing metrics, you've got expenses, and then you've got productivity, provider productivity. And again, with today's day and age with AI, you can build this, whether it's in a spreadsheet or in a live dashboard. Um, I like Manaus for the dashboards, I like Claude for some of those Excel spreadsheet stuff. And you can have it build templates for you where you can input stuff and then it can do the calculations for you. So things. Like provider level revenue that's coming in, provider level visits. I do just want to caution when you're looking at receipts per visit, if you're looking that only at a single month's time, it can ebb and flow depending on patient volumes and collections, if those tend to be uneven in your practice, right? Because you get you're collecting for visits in one month that the visits happened in a prior month. So your collections are happening for prior months visits. And so you just want to be careful that you're even that evening that out. I think looking at this on a quarterly basis is really helpful. And again, that doesn't mean that you can't uh give a uh a profit once a month to, or you know, profit share to a to a provider once a month, you could do that. Um, but you'll just want to make sure that you're thinking about those metrics and whether or not it's smart to measure that on a monthly basis. You know, two years ago, doing this sort of thing was so much harder. And now, even if you're five, 10, 15 practice uh providers, and maybe you don't have a full-time CFO, maybe you have a great bookkeeper, but this sort of like, you know, what does profit look like? How do I track and trend this can get challenging. And so leveraging AI these days, again, I you guys are kind of sick of me saying this, but is very easy and it's not expensive. And you can even have your bookkeeper help you with, you know, the concepts if you're not, you know, used to managing finances at this level. But really having these benchmarks around productivity and trying trending that is really the only way to address performance and have those uncomfortable conversations of I need just see an X number of patients per day, but you're, you know, 50% below that. And really everyone in your practice should know what their ratio of patients needs to be seen, or their average patients need to be seen, so that they know if they're hitting their mark. And I think in small businesses, you want these folks to believe and feel like they are part of the business, which is why I'm so um, I am so like supportive of aligning incentives and profits and so forth to those individuals who are doing the work. Obviously, without benchmarks, um, you know, you're gonna see underperformance subsidizing someone's salary with your own profits or your own patient load. And so with this type of monitoring, it's then no longer a guessing game of people, you know, should get a raise or whether or not they are covering for themselves or whether or not their contract should renew. Like this then becomes a conversation of here's where you need to be, here's how we can get there together, but I need this to happen. Um, and it also turns this into um, how can they help support uh, you know, revenue generating activities? How can they support getting uh patient referrals? You know, who do they know in other subspecialty offices that can get, you know, patients there, say if you're a family practice, or vice versa. And so really, really critical for everybody to be on the same page. All right. And so the last bucket that I think is really important is you think about, okay, I want the ability to step away. How do I do that? Is being able to have decentralized decision making within thresholds. So this means giving certain leads, managers, however you call them, specific financial and operational thresholds where they can make decisions without your approval. And so that may be your front desk being able to make certain decisions about payment plans or, you know, courtesy write-offs, or what you will allow them to put down as a deposit if they have a balance that's due. Putting all of this together in a template that allows maybe a front desk lead, right? So say you have three front desk individuals, having a career path where one of them then is becoming the lead front desk individual who can then help make those decisions on the front desk's behalf. So it's not them always coming to the owner or them always coming to the office manager. It's okay, here are the rules to live by. And they're allowed to do that, obviously with some auditing and oversight by the maybe an office manager, but then it's not always coming to the office manager or not always coming to the owner. You have several degrees of responsibility that again are all clearly laid out so that you can implement those. So, for example, say, you know, you're a five provider group, you're the owner, you're the physician owner, you're seeing patients. But if you're the bottleneck of every $50 write-off or every, you know, $1,000 supply order requires your signature, that is not going to be sustainable. And that's going to be a point of failure. And it's also not the best use of your time. Um, and so your office manager should have certain authorities. But then as you grow, then it becomes what leads in your front desk is what MA lead, what nurse lead, what billing lead can do this on your behalf. Obviously, if you have an outsourced billing team, you need to create those guardrails as well. So, what can you tell your billing team that they have approval to do on your behalf? And here are the lists, here's the list, right? If it's a bundle denial, you don't need to get my approval if we've done X, Y, and Z, things like that. And so, really, really critical for those different points of decisions to be handed off. And I know it's hard. Like I personally am also a one who loves to control things. You know, I think that a lot of us uh who have, you know, done and been successful in life do you have that skill set, but it's um an even uh better sign of leadership if you can start to delegate those decisions. Obviously, you don't want to be in a situation where you're also the one slowing down your operations or your office or not being able to go away without having to be the one to make all of these decisions. So to recap, right, to run a practice that runs without you, you do need a couple of really well-defined systems. All right, so for that recap, the first is going to be that standardized clinical protocol or set of clinical protocols, right? So this is all about the front desk side of things, your MA or patient intake, how you're managing patients behind the scenes, how do you handle patient messages? I mean, every single thing needs to be done. Again, you can build upon it. Don't worry about it being perfect to start. Then the second is that automated financial visibility, right? Looking at those revenue metrics, those billing metrics, those expense metrics all in one central place. We talked about some AI tools. You could use protocol-driven operations, which is really that back office set of protocols, really thinking about your RCM process, how that integrates with your software, getting all of those processes down. And again, if you're struggling with the right group of individuals who are able to do this in your office, that may mean you've outgrown your in-house team and it may be worth looking at an outsourced team. So if you are interested in checking us out, head on over to natrevmd.com and look at that free audit up in the right-hand corner. And then last is that provider productivity benchmarking, right? So really understanding how many patients do they need to be seeing, how are they covering for themselves, and then setting those benchmarks together with your physicians or your providers so that everybody's on the same page with those metrics and those goals, and then tracking that again back in that financial dashboard. And then last is that decentralized decision making. So again, you aren't the only decision maker. Your office manager isn't even always the only off uh decision maker, depending on how big you are. You know, what are those other additional roles or coordinators or lead coordinators able to decide on without your input and without you having to be the one who's troubleshooting? So, really, really important that you build upon this as your practice scales. So, like I said, building these systems is what's going to give you an ability to not just work in the business, but work on the business. We have seen a lot of different practices through their journey as they've grown. We also have different size practices, and those practices that are most successful have this down. Otherwise, I always think like you might as well just be employed if you don't want to be able to build a business that is able to operate like this, especially if you are looking for that business that is multiple providers, multiple locations. Um, and I know it's easy to be really, really busy running in the business, but if you don't step away and run the actual business, it's gonna get even harder to do as as you grow in scale. All right, hopefully you liked this episode. We always love to hear back uh from you guys. So if you um would love to send it through info at notfrabbend.com. You guys have a great rest of your week.