#199 You Are Destroying Half the Value of Every Hire in 90 Days

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The exact framework we use when we walk into a new practice. Takes five minutes. Results are immediate. 

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Only 12 percent of employees strongly agree that their organization does a great job of onboarding. Which means 88 percent of practices — including most independent ones — are spending real money to find the right person, and then handing them a login and a stack of pending items and calling that integration. SHRM data puts new-hire turnover as high as 50 percent inside 18 months. Replacing a billing manager at $55K a year costs between $27,500 and $41,250 per departure. 

This is Part 3 of our four-episode arc. Culture is a revenue decision (EP195). The mindset you hire is the culture you build (EP196). Today we cover what happens after the hire is made. 

Why Traditional Onboarding Fails.  The most common model in independent practice is "trial by immersion": the new hire arrives, gets a login and a senior employee who is supposed to train her when she has time. In hospital systems, the failure is the opposite — bureaucratic theater that produces compliance and nothing else. Both prioritize process over people and treat onboarding as an event rather than a journey. The urgent care group we describe in the episode lost three office managers in 18 months not because they hired badly — because their onboarding communicated, without meaning to, that they did not have a plan. 

The 30-60-90 Structure.  Days 1-30 = foundation and orientation (not productivity). Days 31-60 = supervised contribution. Days 61-90 = integration and ownership. Ownership is not mastery. Mastery takes years. Ownership of a defined scope is achievable in 90 days with the right structure. The piece most practices skip: pre-boarding — a welcome message from the physician before day one that says "you were expected, we planned for you, you matter here." 

Cultural Immersion vs Cultural Assumption.  The most important thing the first 90 days communicate is not operational. It is cultural. A new billing coordinator who reads the mission statement on day one and watches the physician dress down a staff member on day three has received two pieces of information. She will act on the second one. 

The Five Elements of Intentional Cultural Onboarding 

• Physician welcome conversation — five minutes, day one, genuine 
• A mentor or buddy from the existing team with explicit permission to prioritize onboarding 
• A values-in-action story shared in the first two weeks (not the values statement — a story) 
• Early wins by design — a real task completed and acknowledged in the first 30 days 
• Structured 30/60/90 check-ins — three simple questions, not a performance review 

30-60-90 Medical Practice Reference 

Days 1–30 — Foundation & Orientation 

Success looks like: knows the EMR, payer mix, and denial workflow. Has met every person whose work touches hers. Has reviewed the practice's top 10 denial reasons. Has NOT yet worked anything independently. 

Days 31–60 — Skill Development & Contribution 

Success looks like: is working her assigned queue independently with weekly review. Has completed one supervised denial audit. Can articulate the practice's clean claim rate target and where they currently stand. 

Days 61–90 — Integration & Impact 

Success looks like: has identified one billing pattern or workflow gap and brought it to her manager with a proposed fix. Is contributing to team meetings. Has set her first 90-day personal performance goal. 

Sticky Phrase: The first 90 days decide the next three years. 

Three Actions This Week 

• Write a one-page onboarding roadmap for your highest-turnover role. 

• Define the three cultural moments in the first 30 days that will communicate your culture most powerfully. 

• Schedule the 30/60/90 check-ins on the calendar BEFORE the next new hire arrives. 

Episode breakdown 

00:00 — You are destroying half the value of every hire 

03:00 — Why traditional onboarding fails 

08:00 — The 30-60-90 structure 

14:00 — Pre-boarding 

16:30 — Cultural immersion vs cultural assumption 

22:00 — The five elements 

27:00 — Three actions this week 

30:00 — Free resource + close 

👉 RECOVER Diagnostic (free, 5 minutes) 

eligibility.natrevmd.com/recover-diagnostic 

Website: natrevmd.com 

Trusted Resources: natrevmd.com/trusted-resources/ 

Referenced in episode: 

Gallup — State of the American Workplace (onboarding data) 

SHRM — new hire turnover research 

Organizations with structured onboarding programs data (82% retention improvement, 70% productivity improvement) 

The four-episode culture-and-people arc: 

Part 1 — EP197 Culture is a revenue decision: https://podcasts.apple.com/us/podcast/197-the-%2440-000-hire-with-the-perfect-resume/id1624182351?i=1000777698531

Part 2 — EP198 The mindset you hire is the culture you build: https://podcasts.apple.com/us/podcast/198-%24300-000-in-old-ar-is-at-risk-during-your-next/id1624182351?i=1000778180219

Part 3 — EP199 This episode 

Part 4 — EP200 (series close) The performance review nobody wants and how to replace it 

Next episode: EP200 — the two conversation structures (SBI and GROW) that replace the annual performance review with something that actually changes behavior. Series close.

Transcript

SPEAKER_00 0:04

Last week we talked about how to evaluate a candidate's value when it comes to hiring in the office. So today we're going to talk about what happens after the hire is made, right? So you've hired the person and how do you intentionally onboard somebody into your culture and into the role? Welcome to NatrevMD, 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 Signarelli, founder of Nat RevMD. Let's get started. So your onboarding process really has the ability to destroy the value of every hire you make if you don't get this right. It's interesting, there was a Gallup research study that showed that only 12% of employees actually agreed that the organization does a good job with onboarding new employees. 12%. So that's 88% of organizations that are actually hiring the right person, or you spend the money, you hire the right person, you interview them, and then have the potential to lose them because the onboarding process isn't what it could be. And I get it, we're not taught how to onboard folks. There isn't a business class on onboarding. So today I'm going to talk about the strategies that that I've learned, both being in a corporation, but also what I've done within our own company. And I do think that employee turnover decreases when you get this right. SHRM research study actually showed that up to 50% of turnover in the first 18 months is tied to onboarding. And so obviously replacing an employee costs, you know, six, nine months of an individual's salary. So if you are hiring somebody and you're paying them $75,000, $80,000 a year, you could be, you know, wasting $30,000, $40,000, $50,000 depending on how long that role is either open or the cost to actually spend the time to put out a new ad, hire a new person. So getting this right is really, really important. So today I'm going to build out the onboarding structure that I think produces really great results. We have actually never lost a leadership position within our company over the last five years. We have had to let some people go for performance issues, but we have never had anybody leave us. And that is truly, I think, in part the culture. Now, all of these that I'm going to talk about today are applicable to your practice. They're applicable to practices doing several hundred thousand dollars a month. And it will, and by the end of this episode, my hope is that you have a framework that you can hand over to your office manager and to your leadership team so that you can implement before your next hire arrives. And what's interesting is we actually took, so as a company, we have a ton of policies and procedures, right? We run a billing company. So it makes sense that we need policies and procedures both from a high-level perspective. How do we onboard practices? How do we, how do we manage KPIs? How do we manage different roles? But then also policies and procedures related to each individual practice. So lots of stuff to learn for us. So we actually took all of that. I think I've talked about this before, but just to share again, we took all of that and actually created an onboarding website. It is behind a username and password. So they do have to get invited. It's in not anybody can access it. But we were able to create that to go over one, you know, company policies and procedures, right? PTO, all of those things, you know, HR stuff. And then we then go over each kind of component of for us managing accounts, right? So it's things like how to onboard a practice, what are the things we need to complete? And then we actually took, we have that template in Monday.com, which is our project management tool. And then we also have just day-to-day account management. How do we make sure we're managing denials correctly, appeals, AR, patient statements, patient collections when we're working with a practice for those rules? Every single thing. And so we standardized our entire company and then have a tracker. You guys know I love a spreadsheet. We have a tracker for each one of our practices that outlines, okay, where are they in onboarding? Are they stabilized practice? And then where are they in claims, payment posting, AR, patient statements? And then we implement trackers for each of those processes. So all of this to say I took all of that and then created a website that when we have a new employee, a new leadership team member specifically, they can go through each of the modules to understand how we do all of that. I actually even didn't even use video myself. I used PageN to create the videos. And I think I used 11 labs, I'm forgetting now, to make the voice. So then I paired up 11 labs with an avatar video. So it's not me doing the videos, but that's okay. It doesn't need to be me. And then created the modules so they go through every single part of our company. And I think when you think about, you know, traditional onboarding and why it fails is because it's easy to think, oh my gosh, I'm just so glad they're here. I can't wait to just hand them this task of things that have been on my plate I've been covering, or so-and-so has been covering and need to get off my plate so I can actually go do my real job. And so you, you just handle or hand over all of this stuff. Maybe some of it's organized. Maybe there's, you know, some policies and procedures you have them read, but really you're just throwing them into the role itself. And it's like, okay, gosh, go, go do all of these things. I want you to think about taking a step back and go, okay, how do I organize what I'm asking this person to do? And obviously you want to make sure that you're hitting the HR stuff, right? PTO, you know, how to take time off, email, computers, HIPAA, all of the, you know, how do I behave within a company? And then it's about how does my company work from start to finish? So for a medical practice, that may be how do I room patients? What are my rules around, you know, you know, late fees or no-show fees, you know, all of the processes around rooming a patient, your what vendors you work with, like from a billing company, you know, so say this is an office manager coming in, you want them to know every step of the patient journey. For us, it's every step of the, you know, revenue cycle within a practice journey and lay all of that out and then have an easy way to say, okay, here's a high level, and then do the same thing of here are the eight to 10 tasks that this role typically manages. And then let's go into the data and metrics and the expectations for each of those roles. And so it's very easy to have a new hire. They arrive on Monday, you know, they've got a login, they've got a computer, and maybe even you've assigned another employee to train this individual or to help, you know, mentor. But by the time it's the end of the week, you often find out that that, you know, other employee or that mentor has gotten bombarded with their own tasks. And maybe you've been dying to get, you know, the tasks of this new role off your plate, and you've gotten now busy trying to catch up to the six, nine months this person or this role has been open. And so it's easy for that person to go, okay, I'm trying to jump in, I'm trying to help, but that they feel overwhelmed because they don't have a clear picture of how does the organization work? How does the role fit into the organization? And then how is that role going to be successful or what are the measures of success in that role? And so having a central place where first you start and you develop what that looks like in your own mind because you're not going to be able to teach it or share it to somebody else until you get it clear in your own mind. So spending some time going through, okay, how to what are the HR policies within our company? And again, I I know I say this all the time, but with AI these days, you can sit and ask it to help you create, you know, what are the areas that you need to have from an HR perspective? And then working with AI to develop each one of those and make it personalized, ask AI to ask you questions so it doesn't just spit something out that's irrelevant to you, but really thinking through the process by which you want to on by onboard somebody. And again, it's not, you know, maybe you're listening to this and you're going, yeah, we don't have a great method for this. We do, you know, uh fly by the seat of our pants and just somebody has to get jumped in. But I really encourage, especially if you do have high turnover in these uh roles or in the role that maybe you are fulfilling, maybe it's a front desk person, maybe it's an office manager, to again really think through the process by which you want somebody coming into your practice because you spent a lot of time hiring this person and maybe they're wonderful and they have all of the values and the ability and maybe even most of the skill set you need. But if you don't pause for thinking through what that first 30, 60, 90 days looks like, that person may not have the best experience and may either quietly or look for a new role or not give it their all. And so the more time and effort you put into really think about how do I want this employee to, you know, what what actions do I want them doing before you bring them on? I think the better experience they're going to have. Now, I do want to share, I do, I I do find that the that organizations can swing in the opposite direction of this, where it's too regimented and day one, two, and three is spent, you know, looking at webinars and compliance training and benefits paperwork and and you know, you're, you know, then going and having them just just watch videos for the first several days. Obviously, we don't need to go that far to the that end of the spectrum, but I think having a written plan of who are they gonna meet with, what objectives are they gonna have in those meetings, what are the tasks you're gonna say, I need you to learn these tasks first so that you can take these over. What does good look like? And what are the metrics that you're gonna be measuring of what success looks like? And really planning out one-on-ones, either with yourself or with those mentors or with other departments so that they have a chance to sit and listen and learn, ask questions and then go try and do something, and then meeting back with those people to again ask questions, listen and learn, so that it's this iterative process over really that first, you know, 90 days. So I think planning out that onboarding, not just by the end of the first week, but really having some check-ins, those 30, 60, 90 days, really, really is important. And then really asking them the question, like, what doesn't make sense? What haven't I shared with you? What have I missed? What questions do you have? Because I think that's going to allow them to feel supported, to feel cared about, and to feel like you are trying to make it the best experience and welcome them to your uh your company's, you know, culture, your family, et cetera. All right. So next I'm gonna talk a little bit about what that 30, 16, 90 day structure could look like. I'll share a little bit about what it looks like in our company and some ideas around what it could look like within your own company. Obviously, like I said, this is really about a journey. You really need to be more than just that first week. And so defining milestones, clear expectations really in each of the stages of that 30, 60, 90 day is really, really critical. I think if you are the owner and you're hiring your number two. So I'll use that as an example. So say that's a COO, if you're a larger practice, maybe that's an administrative manager. The goal here is regular check-ins. And that's, you know, maybe that first week, that's every single day. Maybe depending on how much this person is your right hand versus delegated to actually run different departments. That cadence may differ for, you know, um, someone as a number two in my company. It may be we're meeting every other day while I'm getting them regular meetings with the departments that they're over so that then they can have introductions, spend some time with them, learn about the different practices. For you, it may be an office manager who needs to come in and really sit and learn what each of the departments do. Go and sit and shadow the front desk, shadow the MAs, shadow the physicians, shadow the back office, meet with the vendors. So maybe that's that first week's task is just to go listen and observe with regular check-ins again, every other day, or maybe even at the end of every day. Each time you meet with them, you could have an opportunity where you go over one culture or one principle or one value about the company so that they start to feel connected and it's not just about the tasks. I think that's really, really important. And then, you know, that second week is okay, what tasks do you need them completing or owning? And then I think creating that while you, when you're doing that 36 to 90 day plan, at the end of 90 days, hopefully they've then learned all of the tasks that they are owners of and that they have realistically taken that on. That doesn't mean that they're not still coming to you in those structured one-on-ones with questions, with, you know, recommendations, but having you help make the decision together until you feel like they've got it and where they can be making decisions independently. And so you have to really go through this structured approach where, you know, really that first 30 days is really about foundations, right? So that may not be a time where they're performing independently, but they're again listening and learning, they're figuring out what team members are going to be working with, what departments they oversee, how the practice works, the software systems, the vendors. So they may not be working completely independent. Maybe they're solving small problems, but it may be taking time. Whereas the second, you know, 30 days, so again, that, you know, 30 day 31 through 60, maybe they're contributing more. Now they've they've gotten to know their team members and they can start taking ownership for specific tasks while still having that, you know, weekly or maybe, you know, two times a week check-ins. Again, just depends on how much this person is your right hand versus their independently managing departments. And so your goal as the owner or as another leader is really just to understand and make sure that you're catching any errors before it becomes a pattern and that this individual is building their own confidence when it comes to making decisions by themselves, but they also feel supported that you're going to catch them should they make a mistake and that they feel comfortable coming to you going, hey, I, you know, like in an S-Bar situation, here's the situation, here's the background, here's my recommendation, you know, do you agree? And if they continue doing, you know, S-Bar type things for small issues or even big issues and the decisions that they're bringing to you or the recommendations they're bringing to you seem correct, then it's like, okay, S-Bar, this individual has got it down. And again, these don't need to be like, you know, thorough S-Bar write-ups. It's just a framework by which you can make sure that somebody is doing it, you know, is working towards independence. I'm a big believer that if I hire a leader, I don't want them coming to me saying, oh, here's the problem, and then no recommendation. The expectation is they know the background of an issue. They've been able to get feedback on an issue, they've dug deep and researched the issue, figured out a few recommendations, and then they're coming to me to just make sure they're on the right track. And so that's very different than you still solving all of their problems in month two. Then month three, this is really about them, you know, moving towards independent operations, right? So they're managing their own responsibilities independently. They're identifying problems before they're even assigned to them, and they're really beginning to start to contribute to the team. And this is really about ownership. So that may not be that they've mastered everything, but they're they're ready to own it. So you're still there to support. And oftentimes, you know, mastery within a project where they're or within a practice maybe may take years, hopefully not, um, but it probably takes six to 12 months. And so ownership is really, so I think as you piece this together, you know, that's why I think doing the pre-work around, you know, what are your HR policies? How many HR policies do you need to have? Again, depends on your practice, depends on your size of team. Um, there's a lot of resources out there that you can at least get a baseline of what you need to have. And then it's the operational day-to-day processes that you need to have hammered out and then down to the roles and then what tasks that they do, and then having those tasks operationally planned out. So that's how I think about building this. So we've got HR, we've got day-to-day operations, we've got roles, and then what tasks those roles perform, and then how to do those tasks. So if you think about like a, you know, a network of policies and procedures, having all of those areas covered down to the tasks that they do, how to do those tasks, how you measure success for those tasks, then those tasks can be assigned to the roles. And the roles when they come in can be fairly clearly defined. And that's going to help somebody have the confidence to know what they should be doing, what good looks like, have some good, quick wins as well. Um, I think the last piece of hiring somebody is making sure that culturally you are welcoming them to your culture. And so obviously understanding what culture you expect. Like for us, I expect, you know, everybody to help each other out within our team, that there are no stupid questions, that we bring issues up to the team and they're not ridiculed, they're supportive of, okay, now how do we solve for that problem? That we are answering client emails quickly. My expectation is that those are happening within 24 hours and that um we are never judgmental either to our team or to our clients in terms of things that aren't going well. And really, really important that those first 30, 60, 90 days, um, new hires within our team feel that, not just hear it on some vision board or, you know, statement that I have on the values of the company, but that they actually feel that amongst their team members. And so you're gonna want to make sure that as the leader, whether you're the physician leader, whether you're a practice manager, you know, that you're embodying and showing that new hire the culture firsthand. And that is really got to be something that, you know, you think about how do I show the person what our values are and make sure that everybody on the team is showing that new hire of those principles. So if you have a department that's full of drama and backstabbing and, you know, wasting time behind you know, behind the scenes, then I think you know, if you're bringing somebody into that department, what do you think they're gonna emulate, right? Are they gonna emulate what the what they're dealing with around them? Are they gonna emulate the drama and the, you know, wasting time, et cetera? So you got to nip that in the bud and say, that's not the expectation here. This is the expectation and and re-re-reaffirm that practices, culture, and values in those departments before those new hires come in. I see that a lot with front desk. It's you've kind of got this simmering negative behavior going on, and you got to nip that in the bud. And I really think nip nipping that in the bud before you hire folks. And if people can't get on board with the culture and the vision and the way you want to operate within your team, put them on a pip, deal with a pip. If I need to do a podcast on pips, I can, and that's a performance improvement plan, not an ideal thing. Obviously, you know, talking to people and showing an example is definitely of, you know, way more preferred. But if all of that fails and you still have an issue, that's when I think sitting down and really understanding, is this the right person for my team? Putting them on a pip really helps protect you as well. Cause if you do have to let go of the staff member, you want to make sure that they understand why that is. Um and is a really good thing for you guys to have that process hammered out to hopefully well before you're hiring somebody. All right. So five elements that I think can be really, really important from a cultural boarding perspective is one, having the owner of the group be able to have a welcome conversation with a new hire. If that person is lower down on the food chain, doesn't need to be a ton of time, but just making sure that they feel welcomed, talk about, you know, what it meant to open the practice and the patients you serve, et cetera. Make sure that, you know, maybe you have a couple of those touch points during that 30, 60, 90 days. Obviously, if you're their direct manager, that's going to be much more involved, just kind of sharing some ideas that that we've seen. Now, um, I do think really important to have a mentor or a buddy from the existing team be assigned to a new hire. And maybe that's somebody in the same department, maybe that's somebody from a different department. And this is really about having a relationship with a specific person who can answer questions or they can start to get to know better on a more personal level, especially if you have a larger team. It's a peer. It's somebody that maybe has been in the role for a while at your practice and knows the context within the practice, knows enough to get by to really be able to help that person. And I like this to not be necessarily just a manager, but really a peer because it just allows them to start having a friend within the practice, which I think having relationships with coworkers helps build a culture where people want to stay. Another, like I mentioned, is really just making sure that values are in action in your practice. Again, if your value is that, you know, you are always kind to patients and that no matter how upset they are, everybody's calm, cool, collected. You make sure that that is practiced around the new hire so that they don't just see this value statement, but they see it in action. Number four is that hopefully those first 30 days, you can have something where the new hire has a task that they can have some quick wins where they feel accomplished, where they're like, yes, I did a good job. And there's an ability to praise them for that good job. There's nothing worse than feeling like, gosh, am I doing a good job? Am I not doing a good job? And so having some tasks that they can own that is easy to do or just, you know, part of their role, but something that they should be capable of accomplishing, so that then you have an opportunity to give a shout out to praise them. And last, really important to have that structured check-in at a 30, 60, 90 day mark. Again, whether that's the owner just depends on whether or not how big the practices are or somebody higher up than just their day-to-day manager, whether that's an owner or somebody, you know, maybe a skip level, two levels up, can be really important. It's just a conversational way for us to go. Do you feel like you're moving in the right direction? How are you doing? And other things I can answer. Do you feel like your role is clear? Do you feel like you're making progress in learning the culture, learning the role, learning the tasks? Again, this is meant to be an informal check-in, but gives the ability for you to check in and really, you know, share any feedback. If they're way off base or showing up late every day, you certainly want to make sure that that's nipped in the butt early. So the three tasks I want you to walk away with is really having an onboarding roadmap for your highest turnover role that you can use as you move to hiring those people here in the next, you know, six months, say you're hiring for that role, really thinking about that HR infrastructure, your operational duties, and the roles and the tasks that those roles are doing, really focusing on what success looks like. And then second is really thinking through okay, how do I show and make sure that our team is showing what it means to be on this team, meaning the cultural values part, how do we make sure that that shines through for our new hires? So, third is really scheduling those 30-day check-ins before the next hire starts, identifying who they need to meet with and figuring out how to get them ingrained into the office role and the tasks that they're going to be doing. All right, so we do have a recover diagnostic down in the show notes. It's a link that allows you to understand where your practice is and figure out if you need to be changing directions with regards to revenue. So go check it out. And as always, if you are looking for a new full service medical billing company, we love to see if we're the right fit for each other. Head on over to our website at natrevmd.com and you can check out the free revenue metric up at the top right hand corner, or just select the contact us and reach out. All right, hopefully, you guys have a great rest of your of your day.