Optimizing Fee for Service with Medical Billing Expert Heather Signorelli, DO

Many thanks to Heather Signorelli, DO, for joining me on The Art of Medicine with Dr. Andrew Wilner. Heather is a practicing pathologist and owner of a medical billing company. Heather’s interest in medicine and business began at an early age. Her father was an obstetrician for his entire career, and her mother was involved in hospital management.

At medical conferences, physicians who struggled with running their offices frequently asked Heather for help and inspired her to start her company. Heather began her medical billing business with her husband five years ago. Currently, she supervises 70 employees and assists 200 physician practices in collecting payments for their services. 

The current complexity of the number of carriers, plans, and rules conspires to prevent physicians from receiving prompt reimbursement for their services. The industry average is 40 days to get paid, although Heather’s company tries to shorten this considerably. Heather explained the top 3 things that physicians can do to improve collections. 

During our 30-minute discussion, we explored the growing concept of the Concierge Practice, which is a cash-based model. We also addressed the role of AI in streamlining office procedures and controlling overhead.

Micro-practices, as presented on this program by Kara Pepper, MD, on August 31, 2025, are another option to traditional insurance-based practices. Both Dr. Pepper and Dr. Signorelli have studied with business guru and pediatrician Dr. Una, featured on this program last December, 2024. 

To learn more about medical billing or to contact Heather Signorelli, DO, please check out her website:

https://natrevmd.com/about-us/

Dr. Signorelli also hosts the NatRevMD podcast, a business-oriented podcast for physicians that airs twice a week:

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Transcript

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[Andrew Wilner, MD] (0:08 - 1:49)

Welcome to the Art of Medicine, the program that explores the arts, business, and clinical aspects of the practice of medicine. I'm your host, Dr. Andrew Wilner. I've planned a great program for today, but first, a word from our sponsor, locumstory.com.

Locumstory.com is a free, unbiased educational resource about locum tenens. It's not an agency. Locumstory answers your questions on their website, podcast, webinars, videos, and they even have a locums 101 crash course.

Learn about locums and get insights from real life physicians, PAs, and NPs at locumstory.com. And now to my guest. Before we get started, I'd like to thank all my followers here in my hometown of Memphis, Tennessee.

Today is episode number 150 of the Art of Medicine. So I took a look at my stats and 10% of downloads were from Memphis. Yay.

Thanks everyone and everyone else all around the world. My guest today is Dr. Heather Signorelli. Heather is a physician and owner of a medical billing company, an uncommon combination, but it might be a logical and synergistic one.

In the last episode, I spoke with CPA Paul Sippel about retirement and saving in 401ks, but there's no 401k unless the practice is profitable. And that's where Heather comes in. So Heather Signorelli, thanks for joining me.

[Heather Signorelli, DO] (1:49 - 1:51)

Awesome. Thanks so much for having me. I appreciate it.

[Andrew Wilner, MD] (1:51 - 1:58)

Heather, let's learn a little bit about your background as a physician and entrepreneur.

[Heather Signorelli, DO] (2:00 - 2:59)

Yeah. So physician. So I'm a pathologist.

So not a typical combo when it comes to medical billing, but I've been on the business side of healthcare really since the beginning. So even in residency, I was doing consulting work. I just loved it.

And I think my dad was an OBGYN. He ran his own practice. My mom ran hospitals.

So I think that just business side was something I've always been around and I love and truly got out of fellowship within the first 24 hours was put in charge of some hospitals in terms of the laboratory side of things. And then that went from one hospital to five to over 180 that I do in my day job. And I just, I love that part of medicine.

I like that physicians are in those leadership roles because it allows us to kind of think about the clinical part, but then also the business side and marry those together. So it's maybe not exactly what I planned, but it has worked out.

[Andrew Wilner, MD] (2:59 - 3:01)

So it was kind of in your genes. It sounds like.

[Heather Signorelli, DO] (3:01 - 3:02)

A little bit.

[Andrew Wilner, MD] (3:03 - 3:47)

Let's figure out. Well, I'm very interested in this because it wasn't in my genes. If I saw anything that had to do with numbers and money, it's like I ran the other way.

And I think a lot of physicians are like me. They're much more interested in the, frankly, the Krebs cycle and suturing than they were learning about medicine. Unfortunately, there's some consequences to that.

And we do live in a world where understanding finance is critical. So first you work, you have a day job as a pathologist. Sounds like that's pretty demanding covering a lot of hospitals.

And so how do you balance that with billing? What do you actually do?

[Heather Signorelli, DO] (3:47 - 3:49)

Yeah. So we have a team of 70 now.

[Andrew Wilner, MD] (3:50 - 3:50)

So there you go.

[Heather Signorelli, DO] (3:50 - 4:58)

Wow. There we go. So in a whole administrative team, we actually, I actually opened this with my husband about five years ago.

And so from the get go, we were hiring individuals who were experts in the billing and coding world. I understand the high level. I understand, you know, revenue cycle when it comes to lab and pathology and obviously, you know, now beyond that from a subspecialty perspective, but, but yeah, we, we, we hired from day one and an incredible team who, who we've built up over, you know, it started with one.

Now we have 70 individuals and, and, you know, I think the biggest thing is, you know, just solving a problem, right? We, why we did it was we had physicians who were coming up to us at conferences coming up to me specifically who were saying, struggling post COVID, can't figure out how to pay my bills, revenues, a challenge. And I love a spreadsheet.

And so I thought, well, we can hire really good people. I know data really well. I know a process really well, like those are my two superpowers.

And so if we can combine that with a really talented team we could do a better job.

[Andrew Wilner, MD] (4:59 - 5:53)

I was in private practice for eight years and I wasn't directly involved with the running of the business. But I remember that collecting the money that you billed and overhead were, were huge problems. I mean, you would send a bill and it would go to the insurance company and then it would get lost or get delayed and then you'd have to send it again or it would get denied.

I mean, there was this huge churning. I mean, imagine you went to the supermarket, right? You're in the checkout line, you've got a hundred items and you, you know, you present your credit card and the lady says, oh no, we're not.

We're not accepting, you know, visa today. Today's, I mean, there were so many ins and outs of it that it all seemed designed really with a complexity to ensure that the physician actually didn't get paid. That seemed to be the goal of the whole thing.

Is that still the case?

[Heather Signorelli, DO] (5:53 - 6:34)

Yeah. Yes, it is. It's probably gotten worse because there's all kinds of other hoops to jump through.

I mean, it is a pain. On one hand, I get it, right? Physicians are, we've got to communicate to the insurance companies why they're paying, what they're paying for and yada, yada, but the complexities of the number of carriers, the number of plans, the number of rules that each individual plan can have is astronomical and getting paid is not easy.

You know, it takes on average, you know, industry benchmark is it takes 40 days for a claim to get paid. We try and get that closer to 20 depending on the type of practice, but yeah, it's a pain. It's a pain.

[Andrew Wilner, MD] (6:34 - 7:07)

Because I understand, you know, there's a movement towards what's called the concierge practice, which many physicians, certainly when I was sort of a developing physician, we thought it was very unethical because you're going to be denying care to people who can't pay. But the premise of the concierge practice is that people pay. Yeah.

Yeah. Cash. They render a service and then they pay you.

It's very old fashioned. Yeah. And it eliminates all of this churning, which is frankly very, I mean, why do you need 70 people?

[Heather Signorelli, DO] (7:07 - 7:35)

Yeah. Well, we have a couple hundred, we have a couple hundred doctors we bill for. So we have a, we, but you're right.

I mean, it, you know, in a cash based model is becoming more popular. We certainly have practices that do that. You know, that comes with its own challenges in terms of marketing and membership structure and collecting from patients up front and so forth.

But I mean, concierge works. I mean, and if you're in a field and in a subspecialty that you can do that, that's certainly one approach, a hundred percent.

[Andrew Wilner, MD] (7:36 - 7:50)

Now on this program, I interviewed on August 31st, just less than a month ago, Kara Pepper, Dr. Kara Pepper, who I understand is a good friend of yours. Yeah.

[Heather Signorelli, DO] (7:50 - 7:50)

I know her.

[Andrew Wilner, MD] (7:51 - 8:58)

And Kara is a physician coach and a practicing physician. And her expertise is helping physicians succeed in private practice, which until I talked to Kara seemed to me to be something that was fading. But her thesis is, well, with AI and telemedicine, you can really lower these overhead costs of doing your job, which I remember was over 50 percent.

This is 30 years ago, you know, of having the office and administrators and magazines, you know, and billing and paying the rent and utilities and insurance. I mean, so that patients would get these huge bills and say, wow, you just spent 15 minutes with me. Why am I getting this huge bill?

Well, number one, you know, most of them didn't pay. And number two, we never got that money anyway. And the money we did get, most of it went to overhead.

So it seemed like a very unsuccessful model. But Kara thinks it can be done. What do you think?

[Heather Signorelli, DO] (8:59 - 10:19)

I agree. I mean, so there are micro practices, which is something similar to what Kara does. Granted, she does more telemed, but then there are other micro practices where they actually do an in-office rent a space, maybe have a very small space, maybe only one additional staff.

And then we're seeing still, you know, the continued growth and use of traditional practices, right? With all the overhead, you know, you're right. It is common to have a 40% net profit margin on a lot of these practices, maybe even lower depending on how you run things.

So yeah, I mean, all the things you said is true. I think from a physician standpoint, you have to decide what kind of practice model do you have, right? What specialty are you in?

Can you do just telemedicine? Do you want a micro practice where it's just you and maybe one other MA or front office person and you do cash? I actually think that's kind of the nice thing about medicine today is you can do locums.

You can open up a micro practice. You can do telemed. You can run a massive multi-location practice if that's what you want, but you have to make the decision and decide, okay, what kind of practice do I actually want to have?

Or do I want to go be employed? I mean, that's, I mean, there's a plethora of options. Do I even want to go do something completely outside of medicine?

We see physicians now doing real estate and all kinds of other random things. So I think it just comes down to what do you want your day to look like?

[Andrew Wilner, MD] (10:20 - 11:00)

I think that's a great point because in my day, you just sort of joined a practice and off you went and you kind of dealt with these obstacles as they came up, usually with no background to do it. But I think intentionality seems to be the key word of the day that now you really have to decide ahead of time is like, okay, this is what I'm willing to do. This is what I want to deal with.

I worked locums for many, many years and locums is kind of the opposite. All you do is show up. You know- That's kind of nice though.

Simon. Oh, I loved it. You just show up and you practice medicine.

[Heather Signorelli, DO] (11:00 - 11:03)

Right. That's all you have to do. Get a paycheck and just walk out the door.

[Andrew Wilner, MD] (11:04 - 12:29)

Practice medicine. I loved it because, well, I was always doing a million other things and I was writing and doing journalism and traveling and doing some underwater photography. But when I worked, that was 100% involvement, dedication, focus.

This is my time to work. I'm going to work. And then when it was over, it was over.

It was all done. Continuity was an issue, but neuro-hospitalist practice, which is kind of what I evolved into. I was one of the first neuro-hospitalists.

There's not a lot of continuity in that kind of practice anyway. Patients get admitted. You see them for an average of 4.3 days, sometimes a lot longer, sometimes shorter, and then you're done. And with any luck, you don't see them again. You don't want them bouncing back in the next month. So by its very nature, the concept of, oh, I'm going to have the same primary care doctor for 30 years doesn't really apply to the hospitalist model.

So locum tendens work very, very well for me. This is a very specific question about locum tendens, and maybe you know the answer and maybe not. But I know when you sign on a locum, or when a locum tendens physician signs on, sometimes they bill under somebody else's number.

Can you explain that?

[Heather Signorelli, DO] (12:29 - 13:17)

So it may be that they'll have typically the locum's doctors under a group that's then doing the billing. And sometimes that's with the hospital. Sometimes that's with an external kind of third-party group.

So it just depends on how that's structured. But someone is billing for you. So it's either, again, through that group or through the hospital or some sort of third-party mechanism of managing the locum tendens physician.

So it just depends. We do not currently bill for any locum's groups. We have kind of a mix of single-practice docs to doctors' practices that are 20, 30, 40 docs and multi-locations.

So I think the option, though, of managing locums or other practices just depends on how you're structured and who you're electing to do your billing.

[Andrew Wilner, MD] (13:18 - 13:27)

Okay. So before we go too far, it sounds like you know what you're doing. So how do people get in touch with you?

[Heather Signorelli, DO] (13:28 - 13:39)

Yeah. So we've got a website, natrevmd.com, but we also have a podcast. So I don't quite have as many episodes as you.

You're at 150. I think our last was 115.

[Andrew Wilner, MD] (13:40 - 13:42)

Oh, well, a lot, many.

[Heather Signorelli, DO] (13:42 - 14:12)

We've got a lot. So that's a place where people can go and take a listen. And we just talk about business, right?

The number one reason why we did this is to educate physicians. Like you said, we don't always get the education in this, and it's not something that we're bred, I think, to learn and do in training. And so my hope is just to share the lessons that we're learning, the lessons that our practices have been through, and just help folks be successful in whatever choice they make in terms of how they want to practice.

[Andrew Wilner, MD] (14:12 - 14:26)

Now, you mentioned, I think, before we started recording, that you and Dr. Pepper had been in some business group together, which seemed really phenomenal, because I didn't know that. So what was that all about?

[Heather Signorelli, DO] (14:26 - 15:09)

So we were connected through Dr. Una, who I believe you know, at EntreeMD. So she's got a business school that helps physicians who want to do entrepreneurship. Actually, her and I were just exchanging messages earlier today about a joint thing.

Her and I are going to get organized. So yeah, I mean, and I do think there are select physicians who are kind of leading this moment, herself included, Dr. Una, who are saying, hey, if you want to be an entrepreneur, you can. This is kind of her path that she's been able to teach and do.

I'm sure there's others, but it's been very successful for us. And it's successful for many different physicians who are like, I need to learn more. Where do I go?

So huge shout out to Dr. Una.

[Andrew Wilner, MD] (15:11 - 15:29)

So hypothetically, I'm back in private practice. Our billing is a nightmare. I know that.

I don't know how to fix it. It's outsourced to some no-name billing firm. And I want a different one.

How do I find one? What questions should I ask?

[Heather Signorelli, DO] (15:30 - 17:09)

So I think the first thing you've got to do, if you're looking at your billing, is really understand, OK, what do my metrics look like? And if you're thinking to yourself, Heather, I don't know what metrics are. I don't know what any of them mean.

Most billing teams will sit with you and go through current state. So they'll go into, you know, either ask you to pull the reports or go in and they'll pull the reports. You've got to understand where you're starting to get a plan for where you're going.

And a huge believer in that. And need to understand what the current struggles are so that you can find a team that can help. I would say the number one mistake that we see with billing teams is that they have, like you said, a lot of accounts receivable, right?

Hasn't been paid. And you've got to understand why that is. We see a lot of operational workflow challenges, either within the billing team or within the office, that create that accounts receivable that just kind of continues to increase.

And so when you're searching for a new billing team, you know, having them do that audit, understanding their communication, you know, how do they communicate with their clients? Is it weekly meetings? Is it do you have an assigned account manager?

How often do you get to meet with them and, you know, figure out what's going on? Because inevitably, whenever you take on a new client, there's a there's a book of work that has to get fixed, right? And so you've got to get a plan around that book of work that needs to get fixed.

And somebody at a high level needs to be able to step that out for you. And then last would be, you know, are they going to give you metrics regularly? That's a must.

You got to have monthly metrics to review. And then do they have the right folks on the team who know your subspecialty and know how to help address issues you have?

[Andrew Wilner, MD] (17:11 - 17:18)

What kind of payment model is there for billing teams? Is it a flat fee or do they get a percentage? How does that work?

[Heather Signorelli, DO] (17:19 - 18:20)

Most states, there are some states that don't want you to do a percent, but most companies do percent as long as you're not in one of those states, which I don't have off the top of my head. I know New York is one that you need to do a flat rate if you have a client in New York. But most it's by percentage, which I think is smart because it aligns everybody to the same goal.

Right. And we even incentivize our even staff based on those metrics as well, because if everybody's incentivized at this in the same way, you're going to have a much higher likelihood at even that front level staff that we're all aligned in the same direction. I mean, and just like we recommend front office staff right in a practice, they all need to be aligned to the same thing.

If they're collecting patient balances up front and you can see that they've collected 90 percent, they should also be rewarded for that sort of alignment. Again, huge fan of alignment. And that's with any staff or any role in a company.

You know, this is not news. It's just something I recommend.

[Andrew Wilner, MD] (18:21 - 19:03)

Periodically, I get these anonymous emails from some company somewhere that's telling me that my coding could have been better if I did this or I did that. Usually it's pretty irrelevant to what I was doing. I don't know what book they use to say what I should be doing.

But it seems to me that as long as coding is still a thing, you know, it's a level two or a level five, that AI should be able to look at your note or look at the problem and just do it and figure it out. I mean, can't AI do that?

[Heather Signorelli, DO] (19:03 - 20:21)

We're getting there. We have some softwares that we work with that do AI coding for the practices. Typically, so for our billing company, we code for some practices, but most practices, the physicians are doing 100 percent of the coding themselves.

We'll address modifier issues when we scrub the claims. But in general, the physicians are doing that. I'd say AI is getting better, but it's not 100 percent.

So actually, some of those softwares that have started building AI coding into the platform have had some lawsuits related to the coding. At the end of the day, the physician is the one that is responsible for the coding. So even if you have AI helping you, you still have to know what you're doing, because if there's AI upcoding things, which is what the lawsuit was about, it is still back down to the physician if there are recoupments that need to happen.

So it is a tricky thing, the coding world, and they change every year. There's codes that get outdated. There's modifiers that change.

So it is important to kind of understand some of that. I think AI is going to get there. It's just we keep looking at towards it from a company perspective to see what we can improve in our efficiencies and workflow.

We're so close, but not quite there yet. We're staying on top of it, trying to see what problems it can solve.

[Andrew Wilner, MD] (20:22 - 20:51)

Because I have made an honest effort to try and get the coding right. But when I look things up, it can be overwhelming. I'm an epileptologist.

What kind of... Were the seizures on the left side or the right side or the front or the back? Or were they simultaneous?

Or was it idiopathic? Or was it cryptogenic? A lot of times, the coding terms actually don't make any sense medically anyway.

They don't really apply to the patient. So it's like, well, I'll just pick one so I can move on.

[Heather Signorelli, DO] (20:53 - 21:19)

And it's funny. Mistakes do happen. And even if they do happen, they don't always impact the revenue.

And so good to have a certified coder who sits down with you and reviews once a year. Like, hey, can I just let... Give me some charts to review.

And they'll sit down with you and do education. And we have coders on our team that will do that with practices. And they'll sit down and they'll say, okay, here's what I would have done.

Here's the education around it. And that can be really helpful.

[Andrew Wilner, MD] (21:21 - 21:31)

What are physicians doing to optimize their billing in these many, many practices? What's kind of the way to make this work?

[Heather Signorelli, DO] (21:32 - 23:15)

So the number one thing, and it's funny. It's the staff in your front office that really start the billing process. And that is the most important role of your office.

I know oftentimes they may be on the lower end from a pay perspective, but it is the most important. So the number one thing we tell practices is really getting what's called the eligibility process at the front desk solid. Because that's the number one denial we see from a billing company in any of our practices.

Those are the individuals who check, is the insurance active? Does the patient actually have coverage under your contracts? Do they have coverage for the type of service you're going to be providing?

And making sure any copays or deductibles or all that patient balance stuff you know ahead of time, because guess when is the most important part to collect a patient payment? Certainly not after they've left your office with the service provided. It's before you have a service done.

I mean, just like your grocery analogy, we pay for our groceries at the time we purchase them. And so if there are patient balances that you know are going to be there, like if the patient has a copay or deductible, please collect them at the time of service because it does get harder to collect. So I would say that's number one.

Number two is understanding your denials, right? So understanding why things are denying so that you can fix root causes like eligibility issues or coding issues. And then number three is to have metrics that you review every month and that you understand.

And I mean, those are the top three things that if you can get those. And again, it may not be perfect on day one. You may have to work on it slowly, but just pick one of those to start.

Then every month, continue to make progress on those and you can have a thriving practice.

[Andrew Wilner, MD] (23:16 - 23:27)

So it sounds like you need a business manager or a physician champion or somebody who's spending an hour a day making sure this happens.

[Heather Signorelli, DO] (23:27 - 23:54)

If not an hour a day, if you've got a small practice, you at least need an hour a week that you are sitting down and understanding these. And maybe in the beginning of a transition, it's an hour a week because you've got problems you fix and then you kind of help those along. The most successful practices we have are really engaged physicians and who are willing to understand the metrics and a rock star office manager.

A huge fan of office managers. They are worth their weight.

[Andrew Wilner, MD] (23:55 - 24:01)

Do you recommend that they be incentivized also in terms of their compensation?

[Heather Signorelli, DO] (24:01 - 24:49)

I think in most companies, now this is probably from my corporate world, I think all employees need to be incentivized. For doing a good job, right? You've got to communicate what those shared goals are, figure out how that individual takes part in those, right?

Are they growing the practice? Are they helping no-shows? Are they helping collect patient balances?

What's their role? And then incentivizing in some sort of bonus structure. Hey, these are the things you control that impact our bottom line.

If you can get these three things accomplished, here's the bonus at the end of the year or end of the quarter, or however you want to structure it. And of course, you could have some sort of threshold that if the practice isn't doing well, nobody gets a bonus. I get it.

But you've got to have shared goals. I think in order to have a successful business, that's imperative.

[Andrew Wilner, MD] (24:51 - 24:55)

I like that. A pat on the back doesn't always cut it.

[Heather Signorelli, DO] (24:56 - 25:01)

No. People are motivated by money. I hate to say it, but people are motivated by money.

[Andrew Wilner, MD] (25:01 - 25:37)

You know, the bills really don't respond to that just OG kind of response. They want to check, right? They want to see the cash.

And the cash is always flowing out. So there do have to be ways to make it come the other way, right? So keep the circle going.

Heather, this has been terrific. Very informative. And you seem to have a really great handle on what's going on in the medical, billing, and business world.

Is there anything you'd like to add before we wrap up?

[Heather Signorelli, DO] (25:38 - 25:51)

You know, I think number one is hiring strong people, finding good teammates, whether they're in-house billers or outsourced that you can trust and have a good working relationship with. And yeah, check out our podcast, NotRevMD. And it was great just spending some time with you today.

[Andrew Wilner, MD] (25:52 - 25:56)

Heather Sidnarelli, thanks for joining me on the Art of Medicine.

[Heather Signorelli, DO] (25:57 - 25:58)

Thank you.

[Andrew Wilner, MD] (25:58 - 28:29)

And now a final thanks to our sponsor, LocumStory.com. LocumStory.com is a free, unbiased educational resource about locum tenens. It's not an agency.

LocumStory exists to answer your questions about the how-tos of locums on their website, podcast, webinars, and videos. They even have a locums 101 crash course. At LocumStory.com, you can discover if locum tenens make sense for you and your career goals. What makes LocumStory.com unique is that it's a peer-to-peer platform with real physicians sharing their experiences and stories, both the good and bad about working locum tenens. Hence the name LocumStory. LocumStory.com is a self-service tool that you can explore at your own pace with no pressure or obligation. It's completely free. Thanks again to LocumStory.com for sponsoring this episode of the Art of Medicine. I'm Dr. Andrew Wilner. See you next time. This program is hosted, edited, and produced by Andrew Wilner, MD, FACP, FAAN. Guests receive no financial compensation for their appearance on The Art of Medicine.

Andrew Wilner, MD, is a professor of neurology at the University of Tennessee Health Science Center in Memphis, Tennessee. Views, thoughts, and opinions expressed on this program belong solely to Dr. Wilner and his guests and not necessarily to their employers, organizations, other group, or individual. While this program intends to be informative, it is meant for entertainment purposes only.

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