RevMD

Send us Fan MailA lot of practices are quietly paying for an AI tool and the staff it was supposed to replace. Same problem, double the cost. In this episode, Dr. Heather Signorelli talks with Simon (Dorien Simon) of Narrows Advisors about where AI actually works in medical billing right now, where it does not, and how to avoid the mistakes that waste the most budget. The Last Mile Gap: EHRs and most AI vendors handle a large share of a workflow automatically, but the final action (officially submitting an appeal, adding the codes, hitting send to the clearinghouse) is often still a human decision. Simon walks through why vendors tend to stop short of full ownership. Buy vs Build Isn't the Real Question: Simon explains why practices get stuck comparing vendor feature lists instead of first mapping their own denial and labor data, and why that order matters. Where AI Is Actually Ready: Eligibility verification and AI scribes are the two most mature use cases today. AR and denial management, despite being everyone's biggest pain point, remain the messiest and least automatable part of revenue cycle. The Double-Paying Trap: Buying an AI license without reducing your team's hours means paying for the software and the staff. Simon breaks down how to actually estimate expected time savings before signing anything. Change Management Is the Real Blocker: If staff believe AI is coming for their job, they will not train it well, or they will leave. The reframe that works: this changes the work, not the headcount. You Need a Referee: Vendor integration typically takes months, not the “seven days to live” promised on a sales page, and it needs one internal owner coordinating IT, testing, and the vendor relationship. Reference tables: None this episode. Three Actions This Week •  Map where your team's time and your denial volume actually intersect, before you take a single vendor call. •  Ask any AI vendor pitching you exactly what percentage of the workflow they handle end to end, and get specific about what is left for your team. •  Name one person internally, even part time, who will own vendor integration, testing, and IT coordination before you sign anything. Resources (CTA priority order) 1. 30-Day Revenue Recovery Plan: eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan 2. Watch the NatRevMD Briefing (VSL): eligibility.natrevmd.com/vsl 3. Payment Posting Audit Checklist: eligibility.natrevmd.com/payment-posting-checklist 4. RECOVER Diagnostic Quiz: natrevmd.com/quiz 5. Guest resource: Narrows Advisors, narrowsadvisors.com 

Send us Fan MailMost payer negotiations start with a feeling. This one starts with a number: percentage of local Medicare, the single most useful tool for comparing payer rates. The one number: Percentage of local Medicare turns a raw dollar amount into something comparable across payers, localities, and codes. Step 1: Pull 12 months of paid-claim data by payer and CPT/HCPCS code, using allowed amounts and units, not charges. Step 2: Rank opportunities by payer, CPT, annual units, and revenue gap, not by frustration. Step 3: Build a focused, five to ten code evidence package that pre-answers the payer's objections. Three actions this week: Pull 12 months of allowed-amount data for your top 10 to 20 codes by payer Calculate percentage of local Medicare for each using the CMS Physician Fee Schedule Look-Up Tool Rank by annual revenue gap, not by which payer frustrates you most Episode breakdown 00:00 Hook and EP213 callback 00:45 The reframe 02:30 The one number: percentage of local Medicare 06:00 Step 1: pulling the right data 10:00 Step 2: high-volume, low-rate intersections 13:00 Step 3: building the evidence package 17:00 The five takeaways 19:00 Close and next episode Resources Practice Revenue Leak Scorecard: eligibility.natrevmd.com/nrm-revenue-scorecard-v3 30-Day Revenue Recovery Plan: eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan Metrics Audit Review (free, physician-led): eligibility.natrevmd.com/metrics-audit-natrevmd CMS Physician Fee Schedule Look-Up Tool: cms.gov/medicare/physician-fee-schedule Previous episode: EP213, What's Actually Changing in Healthcare Reimbursement in 2027 

Send us Fan Mail2027 is not one reimbursement change. It's multiple changes moving at different speeds, some proposed, some confirmed, and the most expensive mistake is treating all of them like the same fee-schedule cut. Change 1, Medicare rates: CMS has proposed two 2027 conversion factors. The headline percentage is never your practice's percentage. Model your own top codes. Change 2, global procedures: Same-day E/M billed with a global procedure is getting more scrutiny. Documentation, not billing habit, decides whether it survives an audit. Change 3, specialty codes: New 2027 OB/GYN coding replaces the bundled global obstetric payment. The pattern applies to every specialty as codes get more specific. Change 4, digital care: Remote monitoring reimbursement is becoming more conditional on established-patient status, a documented initiating visit, and employed clinical staff. Change 5, rate transparency: Federal transparency files make commercial negotiated rates newly accessible, setting up next episode's data methodology. Three actions this week: Pull your top 20 Medicare CPT codes by allowed dollars Check whether your practice bills E/M on the same day as global procedures, and audit the documentation If you run remote monitoring, confirm employed clinical staff and a documented initiating visit Episode breakdown 00:00 Hook 00:40 The 2027 reframe 03:00 Change 1: Medicare rate nuance 07:00 Change 2: Global procedure scrutiny 11:00 Change 3: OB/GYN as the specialty example 15:00 Change 4: Digital care conditions 18:00 Change 5: Rate transparency 20:00 The three-question diagnostic 23:00 Close and next episode Resources 2027 Revenue Impact Brief: eligibility.natrevmd.com/know-where-2027-will-impact-your-practices-revenue-free-brief-natrevmd Metrics Audit Review (free, physician-led): eligibility.natrevmd.com/metrics-audit-natrevmd Website: natrevmd.com Referenced: EP210, the Modifier 25 framework Coming next: EP214, the one number to know before you negotiate with a payer 

Send us Fan MailResources MoneyFitMD: moneyfitmd.com natrevmd.com Dr. Latifat never learned anything about money in medical school, and by her own account avoided it entirely until fear of ending up like her burned-out attendings forced her to face it. She paid off $200,000 in student loans in about two and a half years without extra shifts, then built MoneyFitMD to help other women physicians do the same. Why physicians pay themselves last Most physician owners don't set out to skip their own paycheck. Dr. Latifat points to a scarcity mindset, a fear that there's never going to be enough, no matter what the actual numbers say. Physicians usually aren't motivated by money itself, they're motivated by security, time with family, and not worrying about the future. The work is connecting those things to an actual plan. The story that changes the stakes Dr. Latifat shares the story of a physician forced to close her practice for health reasons. Because she'd focused all her energy on the business and never built personal wealth outside of it, closing the practice meant she had nothing to fall back on. Her point: your business is not your wealth, it's a separate entity, and your business should be funding your personal wealth, not standing in for it. It's 20 percent math, 80 percent psychology Dr. Latifat's take: physicians are good at the math, they run successful practices and understand billing. What trips them up is behavior. She's writing her third book on exactly this problem. The CEO Money Hour One hour a week, same time every week if possible (hers is Fridays), spent entirely on personal finance, not business finance. It solves two problems at once: not having time, and not knowing what to do with the time you have. Dr. Latifat has clients who've built physical rituals around it, a dedicated space, even a specific mug, because the habit is as much psychological as it is financial. Two paths For physicians who avoid money entirely and want a simple foundation, MoneyFitMD offers a 16-week foundational program covering debt, spending, and the financial basics. For physicians whose finances are stable but who want their wealth and their life to actually line up, there's Wealth Village, an ongoing community built around a broad definition of wealth: money, assets, time, relationships, and play. This week, try this Block one hour this week, same time if you can manage it, and spend it only on personal finance. No business numbers allowed. Ask yourself the question the episode keeps coming back to: if your practice closed tomorrow, what would you personally have? Grab Dr. Latifat's CEO Money Hour download to structure that first session instead of starting from a blank page. Episode breakdown How a GI doctor becomes a money coach COVID and founding MoneyFitMD Why physicians pay themselves last Business success versus personal wealth It's 20 percent math, 80 percent psychology The CEO Money Hour Two paths: the foundational program and Wealth Village 

Send us Fan MailResources Cybersecurity Incident Response Checklist: https://eligibility.natrevmd.com/natrevmd-cybersecurity-checklist natrevmd.com Trusted Resources: https://natrevmd.com/trusted-resources/ A healthcare record sells for 10 to 40 times more than a credit card number on criminal markets, and it cannot be cancelled the way a card can. Independent practices hold that data with the least defense in the entire healthcare system: one IT contractor, a server in a closet, and no one whose job it is to think about security. Attackers know it. Why independent practices are the target Three attack vectors specific to practice settings:  Phishing emails that look like they are from an EMR vendor, billing company, or payer. Remote access set up for telehealth or post-COVID flexibility that was never properly secured. Third-party vendor access, where a billing company or IT contractor gets breached and the practice is compromised through them. What to do in the first 24 hours if you are hit 1.  Isolate immediately. Disconnect affected systems from the network, but do not power them down, powered systems preserve evidence forensic teams need. 2.  Call your cyber insurance carrier first, then your attorney. Do not call the attackers, and do not pay anything without guidance. 3.  Document everything from the moment you discover the breach. This becomes the foundation of your HIPAA breach report if one is required, and the 60-day notification clock starts at discovery. 4.  Do not restore from backup until forensics has cleared the system. Restoring too early can reintroduce the attack. Three asks for your team this week Ask your IT contractor: do we have multi-factor authentication enabled on our EMR, our email, and our remote access tools? If not, when can you turn it on? Ask your IT contractor: when was the last time we tested a restore from our backup? Can you run a test this month? Call your business insurance broker: do we have cyber liability coverage? If not, what would it cost to add it? Episode breakdown Why independent practices are the target Three attack vectors specific to practice settings Five things most practices are not doing What to do in the first 24 hours if hit Three asks for your team this week 

Send us Fan MailResources RECOVER Diagnostic: https://eligibility.natrevmd.com/recover-quiz-lp natrevmd.com Payment Posting Audit Checklist: https://eligibility.natrevmd.com/payment-posting-checklist Show notes A provider sees a patient for a scheduled procedure. A separate problem comes up mid-visit, gets evaluated, and the practice bills both services with Modifier 25 attached. The claim pays, and everyone moves on, until that same claim gets swept into a targeted payer audit because the documentation never actually supported a separate, significant E/M service. The three failure patterns Routine pre-procedure work billed as a separate visit:  Baseline assessment before a procedure, confirming the patient is appropriate, reviewing labs, checking vitals, is part of the procedure. It is not a separate E/M, and Modifier 25 does not apply just because something happened before the procedure. Cloned or thin documentation:  An assessment and plan identical to the note from two visits ago, or a problem mentioned in one line with no distinct plan, will not survive a payer review. The documentation has to show medical decision-making distinct from, and above and beyond, the procedure. Modifier 25 used to override a denial:  A claim gets bundled and denied, someone appends Modifier 25 and resubmits, and it pays. If the documentation never supported a separate E/M, that resubmission was not a correction. It was a workaround, and it is exactly the pattern payer audits look for.The global period trap Global periods run 10 days for minor procedures and 90 days for major surgeries. During that window, routine E/M care for the same procedure is bundled and not separately billable, even with Modifier 25 attached. A genuinely unrelated new problem may have a path to separate billing, but it needs documentation of the unrelatedness and compliance with payer-specific global period rules. Procedural specialties, surgical groups, orthopedics, gastroenterology, dermatology, OB/GYN, carry the most risk here. The five-question audit test 1.  Was a significant E/M service actually performed, beyond the usual work of the procedure? 2.  Is the separate problem, assessment, and management clearly visible in the documentation? 3.  Would the E/M have been separately reportable if the procedure had not occurred that day? 4.  Do current NCCI, global-period, and payer-specific rules allow Modifier 25 here? 5.  Could the practice defend this claim on the medical record alone, not just the modifier? Three actions this week Pull 20 to 30 Modifier 25 claims from the last 90 days across your most frequent providers and run each one through the five-question test. Where claims fail, start with provider education, one conversation with examples from their own documentation, not a policy memo. If more than 20 percent of the sample fails, add a pre-release review for high-frequency or high-risk providers for 60 to 90 days while the pattern corrects. Episode breakdown The setup: what Modifier 25 is actually supposed to communicate The three failure patterns Three cases: yes, no, or verify The global period trap The five-question audit test Running your own Modifier 25 practice audit 

Send us Fan Mail Dr. Emily Ward knew in March 2020 that she was done. She left her gastroenterology partnership in 2023. The reason for the gap was not fear. The practice worked, the money was good, and staying was the rational choice every morning until it was not. She joins Heather to walk through what she built after that, and the part nobody puts in the announcement post: how you actually get paid once you step outside the systems that normally do the paying. THE BACKGROUND Board certified in internal medicine and pediatrics before gastroenterology, with early microbiome research behind her. Ten years in private practice, most of it colonoscopy after colonoscopy with very little conversation attached. THE FIRST PIVOT GutsyRx, an online gut and rectal health marketplace for women, built for the patient she was in 2020: postpartum, perimenopausal, and unable to find anyone to talk to about it. THE SECOND PIVOT The community kept asking when she was coming back to see people in person. She opened a cash-pay concierge clinic in 2025. No payer contracts, opted out of Medicare. THE THREE PAYMENT PATHWAYS Pathway 1: her own cash-pay endoscopy center. She got as far as a pro forma with a consultant who had launched endoscopists before. His read was that she would need payer contracts for the numbers to work, which defeated the point. Pathway 2: employment at a facility, patients paying her consultation fee and running the procedure through insurance. Compliance gets murky against a Medicare opt-out, and she loses the scheduling control that makes high-touch care possible. Pathway 3: the hybrid, and the one she runs. Patients pay her professional fee directly. Facility, anesthesia, and pathology go through insurance or cash, patient's choice. Every patient so far has chosen insurance for that portion. WHAT SHE WOULD DO DIFFERENTLY She would not have built the WordPress and custom e-commerce platform to the depth she did. That capital would have moved further inside the in-person practice. THREE ACTIONS THIS WEEK • Write down which parts of your week you would keep if the revenue stayed flat. That is the list worth building around. • If you run any cash-pay service alongside insurance, confirm the two sides reconcile independently and nothing is being written off into the gap. • Before your next platform investment, ask what the same build would cost eighteen months from now. The answer has changed. OUR GUEST Dr. Emily Ward, MD, GutsyRx gutsyrx.com  |  Instagram @gutsyrx_guthealth  |  LinkedIn: [insert profile URL] FREE RESOURCE Practice Financial Health Dashboard for Physicians eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd RECOVER DIAGNOSTIC eligibility.natrevmd.com/recover-quiz-lp MORE FROM US Payment Posting Audit Checklist: eligibility.natrevmd.com/payment-posting-checklist Everything else: natrevmd.com MENTIONED The 6 Types of Working Genius by Patrick Lencioni

Send us Fan MailPart two of two. If you send a specimen to an outside lab and they bill you eighteen dollars for it, eighteen dollars is the most you can bill Medicare. Not your contracted rate. That is the anti-markup rule, and it is one of two things that quietly rewrite the math on in-office lab. What to pull first. Start from your last 90 days of reference lab orders, grouped by test name and CPT code. That is demand, not a projection. Then map each test to its PAMA rate from the CMS Clinical Laboratory Fee Schedule, and check whether your commercial payers hold a separate lab fee schedule from your office visit schedule. Many do. How Medicare lab billing works. Medicare pays the lesser of your billed charge or the PAMA rate, and there is no negotiating it. Billing $45 against an approximately $18 rate pays approximately $18. The anti-markup rule then says that if you did not perform the test yourself under your own CLIA certificate, you cannot bill Medicare above what the reference lab charged you. And ordering provider enrollment matters, because lab bills under the ordering NPI directly and incident-to does not apply. The four costs that get underestimated. Reagent per reportable result, QC materials run daily whether or not you test a patient, proficiency testing for moderately complex, and staff time. That last one decides it: five to fifteen minutes per rapid test, which at twenty tests a day is $42 to $175 in daily labor. The honest ceiling. On rapid strep at a blended $19 with about $10.80 of variable cost, contribution margin is $8.20 a test and break-even is about 43 tests a month. A practice converting 126 of 180 referred strep tests clears roughly $681 a month from strep alone. A full waived menu at good volume might reach $3,000 to $6,000 a month. Real money, and a real compliance program. Three actions this week Have your billing team pull 90 days of send-out orders grouped by test name and CPT code. That single report is your demand baseline. Look up the current PAMA rate for every test on your candidate menu at the CMS Clinical Laboratory Fee Schedule for your year and locality. Check how your send-out tests are currently being billed to Medicare against the anti-markup rule, before you model anything new. Episode breakdown Segment 1: what to pull before any revenue projection Segment 2: how Medicare lab billing actually works, three rules Segment 3: the business case model and a worked break-evenResources Practice Financial Health Dashboard for Physicians  eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd RECOVER Diagnostic  eligibility.natrevmd.com/recover-quiz-lp CMS Clinical Laboratory Fee Schedule  cms.gov/medicare/payment/fee-schedules/clinical-laboratory Trusted resources library  natrevmd.com/trusted-resources/ Part 1: EP207, should you bring lab testing in-house? 

Send us Fan MailIn-office lab is one of the most common ancillary additions practices consider, and one of the easiest to get expensively wrong. Part one of two: the framework that decides everything before you spend a dollar. What CLIA is. The Clinical Laboratory Improvement Amendments, passed in 1988 and administered by CMS, govern all lab testing on human specimens. Every test your practice runs on a patient sample requires a certificate. Which certificate you need depends on the complexity of the test, not on what you would like to do. The three categories. Waived tests are simple enough for FDA-approved over the counter use: strep, flu, COVID antigen, dipstick, glucose, pregnancy. A Certificate of Waiver runs about $150 every two years with no routine inspection, and the compliance standard is following the manufacturer's instructions exactly. Moderately complex covers CBC, CMP and UA with microscopy, and requires a designated lab director, documented competency, daily QC, proficiency testing and routine inspection. High complexity is hospital and reference lab territory. Getting certified. Confirm your exact analyzer model and test kit are on the CMS waived list, file Form CMS-116 with your state or MAC, expect two to four weeks and about $150, then build your policies and train your staff. Only then buy equipment. CLIA number first, equipment second. The four questions. What are you already referring out that you could run yourself? What does your patient population need at point of care? What is your payer mix for these test types? And do you have the staff capacity and the discipline for the compliance program? The strongest business case is for tests that change the same-day clinical decision. Three actions this week Pull your reference lab orders for the last 90 days and group them by test type. That list is your candidate menu, and it is real demand rather than a projection. Look up your exact analyzer model and test kit on the CMS waived test list at cms.gov before you take a single vendor call. Name who would own the compliance program, and ask them honestly whether they have the bandwidth to do daily QC consistently. Episode breakdown Segment 1: the CLIA framework and the three complexity categories Segment 2: what certification actually takes, waived and moderately complex Segment 3: the four questions that decide it for your practice Resources RECOVER Diagnostic  eligibility.natrevmd.com/recover-quiz-lp Practice Financial Health Dashboard for Physicians  eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd CMS waived test list  cms.gov, searchable by test name and manufacturer CMS Form CMS-116, the CLIA application Trusted resources library  natrevmd.com/trusted-resources/ Part 2: EP208, building the business case for in-office lab testing

Send us Fan MailBefore you build a business case for anything, a new hire, a second location, a new service line, three numbers have to be right. Payer mix. Net collection rate. AR days. Most owners have all three. Almost nobody has calculated them correctly in the last two years. This episode is how to fix that, in about twenty minutes, using your own system.  [Payer mix] The payer mix on your billing dashboard is almost always built on charges, meaning what you billed. What you need is payer mix by collections, meaning what you actually got paid. Those two numbers are often meaningfully different. Pull payments received by payer over the last 12 months, divide each payer by total net collections, and that percentage is your real mix. Twelve months and not three, because open enrollment shifts and Medicaid redeterminations distort any shorter window.  [Net collection rate] Gross collection rate compares you to your billed charges, a number nobody ever pays. Net collection rate compares what you collected to what you were contractually owed. Net collections divided by gross charges minus contractual adjustments. Discretionary write-offs, bad debt and charity, do not belong in that adjustment figure, because including them overstates the rate. Most well-run practices land between 95% and 98%. Under 90% is a red flag. Above 99% usually means contractual adjustments are being under-written.  [AR days] AR balance divided by average daily charges over the last 90 days. Lower is generally better, but the blended number hides the story. Split insurance from patient, then look payer by payer. Under 35 days total is healthy. Medicare should sit at 20 to 28. Medicaid at 35 to 60. Patient AR above 40 days means balances are not being collected at the point of service. Any payer trending up for three consecutive months is worth a conversation.  [Why this matters for a business plan] A 10% shift toward Medicaid lowers your blended rate per visit by $8 to $15 depending on specialty. In a 30,000-visit-per-year practice that is $240,000 to $450,000 of annual revenue difference, and it is completely invisible if you are using charge-based payer mix. A practice modeling at 96% when the verified rate is 92% overstates revenue by four cents on every dollar. On $300,000 a month that is $12,000 a month that does not exist. And a plan built on 30-day AR while the practice actually runs at 52 days has a cash flow gap in the first 60 to 90 days that the plan never accounts for. That gap shows up as a cash crisis, not a revenue problem.  [Three actions this week] Pull payer mix by collections: 12 months, by payer, as a percentage of net payments Pull your net collection rate: net collections divided by gross charges minus contractual adjustments, 12 months, run 90 days in arrears Pull AR days for your top four payers, insurance and patient separately, with a 3-month trend direction on each If you cannot pull any of these cleanly from your system, that is the first thing to fix, not the business plan. A plan built on numbers you cannot verify is not a plan. It is a guess with formatting. And if you can pull them and the numbers surprise you, that surprise is worth more than any plan you would have built without looking. Take them to your accountant and your billing manager before you build anything else.  [Episode breakdown] 00:00  The three numbers 00:40  Why this matters before you build anything 02:30  Payer mix: what it actually is 05:10  The calculation that matters 06:40  Why 12 months and not 3 or 6 08:20  Net collection rate: the formula 11:00  How to pull it correctly 13:10  What a healthy number looks like 15:00  The number most practices are using is not this 17:00  AR days: insurance versus patient 19:20  What AR days does to a cash flow plan 21:30  What to do before you build anything 23:00  Next week on EP207Practice Financial Health Dashboard for Physicians The workbook version of this episode. Enter your payer mix, net collection rate and AR days and see each one against benchmark, in one place. https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd RECOVER Diagnostic Four minutes. Shows you which part of the revenue cycle is leaking before you go pull anything. https://eligibility.natrevmd.com/recover-quiz-lp 30-Day Revenue Recovery Plan For practices that already know something is off and want a sequence to work through rather than a diagnosis. https://eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan EP204: The Hidden Cost of Running Your Practice Without a Business Plan The episode this one builds on. Why the plan matters before we talk about the inputs. https://podcasts.apple.com/us/podcast/204-the-most-expensive-thing-in-your-practice-is-an-open-note/id1624182351?i=1000783299856EP207: coming next week What happens when these three numbers are quietly off in the optimistic direction. https://natrevmd.com/podcast/

Send us Fan MailA practice hired a provider in January. The hire was right and she was generating revenue from day one. By March the practice was sixty thousand dollars short and could not make payroll, because nobody had modeled what cash looks like in month two when you are carrying a full salary and the claims are still in the pipeline. This episode builds the model that would have caught it, and it is not the binder kind. In this episode:  The seven moments when a practice actually needs a financial model The six components that matter, and the ones you can skip How to calculate net revenue per visit and why everything else depends on it The cash flow projection that shows what a profit and loss statement cannot Break-even, translated into a daily schedule number The five numbers each seat in the practice needs to see RESOURCES FROM THIS EPISODE 1. Practice Financial Health Dashboard (free Excel workbook) The workbook version of the model in this episode. Revenue per visit, the fixed and variable expense split, a 24 month cash flow projection with the payment lag already built in, and the break-even math. You enter your numbers, it does the arithmetic. eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 2. The RECOVER Diagnostic (two minutes) A short set of questions about how your practice runs. At the end you get a read on where the revenue is leaking and which fix we would put first if it were our practice. eligibility.natrevmd.com/recover-quiz-lp 3. Protecting Your Visits From Downcoding (free live session, Wednesday August 26, 4:00 to 5:00 PM CST) Stephanie Hilliard, CPC, on keeping visits from being downcoded and documenting medical decision making that supports a successful appeal. Every registrant gets the physician toolkit: the 90-Second MDM Note Builder, the Is This Really a Level 4 annotated casebook, an EHR SmartPhrase starter pack, the MDM or Time decision card, and the Hidden Work reference. eligibility.natrevmd.com/em-downcoding-webinar 4. The 30-Day Revenue Recovery Plan (free PDF) If the model says the practice should be fine and the cash still is not there, this is the first month of fixes we run, sequenced so you are not repairing six things at once. eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan SYSTEM 1: WHEN A PRACTICE ACTUALLY NEEDS A PLAN Four triggers, not a continuous ritual. Starting the practice, adding a provider, opening a second location, adding a service line, seeking financing, a partnership or buy-in, and a sale or transition. The one owners skip most often is adding a provider, because the hire feels like a revenue decision. In the first sixty to a hundred and twenty days it is a cost decision: the salary starts on day one, the claims do not pay for thirty to forty five days, and full schedule utilization takes another sixty to a hundred and twenty days after that. SYSTEM 2: THE SIX COMPONENTS THAT MATTER The clinical model sets the ceiling on revenue. The revenue model converts capacity into cash through payer mix and net collection rate. The expense structure separates the fixed floor from the variable layer. The cash flow projection makes the payment lag visible month by month, which is what reveals a profitable practice running out of money. The break-even analysis turns the whole model into one daily schedule number. And the KPI dashboard is what keeps the plan alive after it is built. SYSTEM 3: WHAT MAKES IT A DECISION TOOL Three scenarios instead of one, and the downside case is the one that sets your reserve requirement. Stress tests on every assumption, because knowing which ones are high-sensitivity is how you know what to watch after launch. And an operating translation, so the model becomes three or four numbers each person in the practice can act on rather than a file nobody opens. THE CALCULATION, WORKED IN FULL Net revenue per visit $130.63 net revenue per visit Break-even, for a practice with $180,000 in monthly fixed expenses: $180,000 / $131 net revenue per visit = 1,374 visits per month 1,374 / 22 working days / 2 providers = 31 visits per provider per day to break even THREE ACTIONS THIS WEEK 1. Calculate your net revenue per visit.  2. Calculate your break-even visit count. Total fixed monthly expenses divided by net revenue per visit, then divided by working days and providers. That is your daily target. 3. Before any significant decision this quarter, sketch a 90 day cash flow. New expense from day one, revenue with the payment lag applied. If the balance goes negative, you now know the reserve required to fund through it. EPISODE BREAKDOWN 00:00 The hire that nearly broke a practice 00:40 What a business plan actually is 02:30 System 1: the four triggers 08:00 System 2: the six components that matter 09:30 Net revenue per visit 13:00 The cash flow projection 15:30 Break-even as a daily number 18:00 System 3: three scenarios 19:30 Stress-testing assumptions 21:00 The five numbers each seat needs 23:00 What to do this week 

Send us Fan MailA full schedule is not the same thing as a healthy practice. Our guest this week walked into an independent family practice in Colorado to do finance work, was offered the practice manager role a few weeks later, and quickly found the gap: patients were coming in, the schedule was booked three to five months out, and the money still was not moving. What follows is the sequence she used to close that gap, and it starts nowhere near the billing office. In this episode: How to find the fire costing you the most money right now, and why you fix only that one What a week working a role yourself reveals that no meeting ever will The training-first sequence that makes accountability stick instead of driving turnover The leaderboard and the 72-hour standard that moved a five-provider note backlog The front desk scripts that turn a copay ask into a copay collected RESOURCES FROM THIS EPISODE 1. The 30-Day Revenue Recovery Plan (free PDF) The first month of fixes we run when a practice is fully booked and still short on cash. It sequences the work so you are not trying to repair six things at once: what to pull first, what to change next, and what can wait until the bleeding stops. eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan 2. The RECOVER Diagnostic (two minutes) A short set of questions about how your practice actually runs. At the end you get a read on where your revenue is leaking and which fix we would put first if it were our practice.  eligibility.natrevmd.com/recover-quiz-lp 3. Protecting Your Visits From Downcoding (free live session, Wednesday August 26, 4:00 to 5:00 PM CST) Stephanie Hilliard, CPC, on keeping your visits from being downcoded and documenting medical decision making that supports a successful appeal. Every registrant gets the physician toolkit: the 90-Second MDM Note Builder, the Is This Really a Level 4 annotated casebook, an EHR SmartPhrase starter pack, the MDM or Time decision card, and the Hidden Work reference. Free, and nothing is expected of you afterward. eligibility.natrevmd.com/em-downcoding-webinar 4. Practice Financial Health Dashboard (free Excel workbook) The tool version of what our guest did first: get the numbers in one place and look at them. Built for physicians who want the picture without building the spreadsheet themselves. eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 5. Practice Revenue Leak Scorecard A self-scored walk through the places money goes missing between the front desk and the deposit, so you can see which ones are yours. eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Delegation starts with doing the job yourself. When a front desk staffer needed a week off, she covered the desk for the full week instead of observing for an hour. Day one she describes as burnout. By day three she had a flow. What she came back with was not a complaint list, it was a map of what the team was capable of and what nobody had ever trained them to do. Technology is a workload decision, not an IT decision. Ninety percent of inbound calls are not scheduling calls. They are refill requests and follow-up questions, and most of them belong in the patient portal. Push the portal and the text reminders and the phones quiet down, which gives the desk time to do the work that actually gets the practice paid. Accountability comes after training, never before. Her rule is direct: you cannot hold someone accountable for a job they were never properly trained to do. So the checklists came first. Same steps at every check-in and every check-out, so the result is identical no matter who is at the desk. Once the tools exist, the excuses stop and the standard is fair. Turnover in year one is a training problem. Nobody accepts a job without knowing the pay. So when someone leaves inside the first year, it is usually because they are unhappy or they do not know how to do what is being asked of them. Her nursing staff have been there fourteen and fifteen years. The front desk is where the churn lives, and that is a training signal, not a compensation one. The front desk is where collections are won or lost. During her week at the desk, daily copay collections ran two to four thousand dollars against a normal range of eight hundred to a thousand. The difference was not effort, it was scripting. Not "would you like to pay today" but "how would you like to pay today." Not "do you want to book your wellness" but "who would you like to see for your wellness next year." The leaderboard did what memos could not. A backlog of open provider notes was choking the revenue cycle, and reports alone had not moved it. She built a weekly leaderboard ranking providers by open notes, then layered a 72-hour closure policy on top with a real consequence attached, applied to owners and part-time providers alike. Fifteen days into the leaderboard the backlog had dropped by more than 150 notes. Measure the standard, not just the pile. The tracker evolved past a raw count into a percentage: of the notes a provider has open, how many are still inside the 72-hour window. Below eighty percent and they hear from her directly. As Heather puts it, what you do not measure, you do not make progress on.THREE ACTIONS THIS WEEK1. Pull your open encounter count and your AR over 90 days. Do not guess the number, print it. Most practices are surprised by it. 2. Pick one role and work it yourself for a full day, minimum. Not observation. Do the job. 3. Before you ask anyone for accountability, ask whether the training and the checklist actually exist. If they do not, that is this month's project. EPISODE BREAKDOWN 00:00 Meet our guest and how she landed the role 02:30 Delegation starts with knowing what the job actually is 03:38 A full week working the front desk 08:47 Ninety percent of your calls are not scheduling calls 13:37 You cannot hold someone accountable to training they never got 19:58 Nobody quits in year one over pay 21:43 What one week at the desk did to daily copay collections 23:40 The scripts that changed the number 26:11 No job is above me or below me 27:52 The math was not mathing 30:28 The open note backlog and the leaderboard 31:40 The 72-hour policy, owners included 35:13 Measuring the standard, not just the backlog 36:44 Why we are not adding patients yet 38:10 One piece of advice for a practice that is stretched thin 

Send us Fan MailShe never missed a Monday. Twelve months of weekly billing meetings, every number reviewed, every question answered. And by the end of that year her net collection rate had dropped four points, her ninety-plus AR was up forty percent, and her denial rate had climbed from six percent to eleven. The numbers were there every week. The report was accurate. Nothing changed, because the meeting was structured around reporting instead of around deciding. System 1: the financial snapshot. Three numbers, charges, payments posted, and unlocked encounters, each compared to last week and month to date. Payments lag charges by 30 to 45 days, so a strong week reflects submissions from a month ago. And unlocked encounters, the number most owners skip, is the most controllable revenue lever on the report. On a practice doing $350,000 a month, each day of unsigned encounters at scale represents roughly $12,000 to $18,000 in claims that are not in the pipeline. System 2: AR aging, denials, and stuck claims. AR aging by date of service is the patient-facing view. AR aging by claim date is the payer-facing view. The comparison between them is its own diagnostic: if date-of-service aging is older, you had a submission delay. If claim-date aging is drifting past 90 while date-of-service aging sits at 30 to 60, the payer is holding claims that went out promptly. Denials and rejections are also not the same problem: a rejection happens before adjudication and is a front-end fix, a denial happens after and carries appeal deadlines. System 3: the accountability layer. Patient statements, four trackers, the rolling action item tracker, and the onshore manager review. The rolling tracker is the section that makes the meeting matter: eight fields, every item with one named owner and one due date, no item closed without a resolution note. Without it, the same problems get identified week after week and the meeting becomes a theater of accountability rather than a mechanism for it. THE WEEKLY MEETING AGENDA Financial Snapshot, 5 min. Charges, payments posted, unlocked encounters vs last week and MTD. Ask: did we move in the right direction and do we know why? AR Aging by DOS, 5 min. Ask: is the 90-plus bucket growing or shrinking week over week? AR Aging by Claim Date, 3 min. Ask: where are claims stalling after submission and which payer is holding them? Denial Analysis, 7 min. Ask: what is the root cause of the top denial and what closes it? Rejection Analysis, 5 min. Ask: what front-end information gap is generating these and who fixes it? PM System Status, 3 min. Ask: what is sitting in a status that should have moved by now? Patient Statements, 3 min. Ask: are we sending on schedule and is patient AR moving? Tracker Updates, 5 min. Ask: what is still open from last week and does it have a new owner or date? Rolling Action Items, 5 min. Ask: does every open item have one owner and one due date? Manager Review, 4 min. Ask: what is the team seeing that is not captured in the numbers?READING YOUR AR 90-plus growing week over week. Claims aging without resolution. Ask which payer and what status, and whether this is a follow-up gap or a payer dispute. 0 to 30 growing faster than payments. Strong submission, lagging cash. Ask whether this is normal lag or a specific payer slowing down. 120-plus unchanged for 3 or more weeks. Approaching or past timely filing. Ask which claims, what the appeal status is, and whether any need to be written off. Claim date aging older than DOS aging. Submission delay. Ask what caused it and whether it is still happening on current claims. Unlocked encounters climbing. Charts are not being signed. Ask which providers, how many days open, and who is following up today. THREE ACTIONS THIS WEEK 1. Pull your unlocked encounter count today and bring it to Monday. If it is growing, that is the first conversation before any other section gets opened. 2. Ask your billing manager for the rolling action item tracker from the last four meetings. If it does not exist, that is the answer. 3. Write one specific question for each of the three main sections before your next meeting, and notice what changes when the meeting has a questioner in it. EPISODE BREAKDOWN She never missed a Monday | Reporting versus deciding | The financial snapshot | Unlocked encounters | AR aging, two views | Denials versus rejections | Claims status | Trackers and patient statements | The rolling action item tracker | The manager review | Three things to do this weekResources block 1. FREE: Practice Financial Health Dashboard, https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 2. FREE: Practice Revenue Leak Scorecard, https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3 3. Everything else we have built, in one place: https://natrevmd.com/trusted-resources/ 4. Related listening, EP200 and EP201 on building the billing partnership and the shared operating model: EP200 and EP201

Send us Fan MailThe most expensive billing relationship is not the one that is clearly failing. It is the one that is quietly not delivering. On a practice doing $400,000 a month, three points of net collection rate is $12,000 a month. Nobody escalates $12,000. It does not trigger a phone call. It just leaves, month after month, until somebody adds up a year of it and finds $144,000 that nobody ever fought for. This is Part 2 of a two-part series and it builds the operating model that catches it. System 1: the day-to-day operating model. Every good billing partnership has a weekly rhythm and a monthly rhythm, both defined before the relationship starts rather than improvised after something goes wrong. The weekly rhythm is operational on the practice side and communicative on the billing side. The practices that feel most confident are almost always the ones with a short, consistent weekly touchpoint. Not because anything is wrong. Because nothing has had time to go quietly wrong. The five-number report. Most monthly billing reports show collections by payer, claims submitted, and a denial percentage. That is activity data, not performance data. The report that tells you whether the value equation is moving has five numbers: net collection rate, denial rate by payer and reason code, AR days trending over three months, clean claim rate, and patient AR aging by segment. System 2: how to know it is working. Three green flags. Denial root causes are getting identified and closed, not just worked. The practice side is getting easier over time rather than harder. And the leading indicators are moving before the headline numbers do. Three warning signals. The monthly report is not readable or not specific. Problems get explained after they compound instead of flagged before. And the same denial patterns appear month after month without root cause resolution. System 3: what to do when something feels off. The right first move is almost never to start looking for a replacement. Most billing relationships that ended badly were relationships where the right conversation happened six months too late. There is exactly one situation where replacement is the right call: specific commitments were made by both sides with dates attached, and they were not kept after a fair period. THE SHARED OPERATING MODEL Chart Closure. Practice: providers sign charts within 24 to 48 hours of the encounter. Billing partner: tracks chart closure rate weekly and flags delays before they hit the claim cycle. Front Desk Accuracy. Practice: verifies eligibility before every visit, collects copay at check-in, captures authorizations before the patient is seen. Billing partner: trains the front desk on what billing needs and provides feedback loops when errors surface in claims. Denial Management. Practice: backs the billing partner on policy enforcement with payers when escalation requires physician involvement. Billing partner: owns denial follow-up completely, trends by payer and code, reports root causes monthly. Patient Balances. Practice: communicates financial expectations at scheduling and check-in and supports the collections policy. Billing partner: provides a structured patient AR workflow and reports aging by segment. Performance Visibility. Practice: reviews the monthly report and asks questions when numbers move. Billing partner: delivers a clear payer-level report monthly with denial rate, AR days, net collection rate, and trend direction. Communication Rhythm. Practice: shows up to the weekly or bi-weekly review. Billing partner: runs the meeting with an agenda, flags problems before they compound, and proposes solutions rather than summaries. THREE ACTIONS THIS WEEK 1. Ask your billing partner for the five-number report this week, not at the next scheduled review. How fast it arrives tells you as much as what is in it. 2. Check your own weekly rhythm: chart closure rate over the last seven days, eligibility verification rate at the front desk, copay collection rate at check-in. 3. If your billing relationship has been running more than 90 days and you have never run the four-variable review, schedule it this week and frame it as a calibration, not a performance review. EPISODE BREAKDOWN The $144,000 nobody escalates | Bridge from EP200 | Where quiet underperformance lives | The weekly and monthly rhythm | The five-number report | Three green flags | Three warning signals | What to do when something feels off | Three things to do this week Resources block1. FREE: Practice Financial Health Dashboard, https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 2. FREE: EMR / PM Evaluation Framework, https://eligibility.natrevmd.com/emp/pm-evaluation-framework 3. Part 1 of this series, EP200 Know Your Side of the Equation: https://podcasts.apple.com/us/podcast/200-your-performance-reviews-are-making-your-billing/id1624182351?i=10007792563514. Practice Revenue Leak Scorecard, https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3 5. Referenced in this series: $100M Offers by Alex Hormozi

Send us Fan MailA practice doing seven figures a month switches billing companies, and eighteen months later the denial rate is higher than the day they signed. Nobody lied. Both sides just walked in with a different picture of what good looked like. In this episode we run Alex Hormozi's value equation across a billing partnership, one variable at a time, and name exactly what each side owes the other. Dream Outcome. A practice owner hears "we will improve your collections" and pictures denials dropping from 12 percent to 5, AR days under 35, and her team off the payer portals on Friday afternoons. The billing company is picturing a 3 to 5 point net collection improvement over twelve months. Both are honest. Neither is the same outcome. The fix is a written, numeric definition of success before the contract is signed. Perceived Likelihood. The billing partner builds this with evidence: before-and-after denial rates in your specialty, AR trending over twelve months, retention data. The practice builds it with an honest read on its own history. A practice that says "our front desk eligibility rate has been inconsistent and we are ready to fix that" is a fundamentally different partner than one expecting the problem to be solved without any practice-side change. Time Delay. Month one is almost entirely old AR, because new claims will not generate cash for 30 to 45 days. That is not a performance problem, it is how billing cash flow works. But if nobody said it before the relationship started, month one feels like nothing is happening. The ramp has to be mapped out loud, before the contract, not defended at the 60-day mark. Effort and Sacrifice. Chart closure inside 24 to 48 hours. Eligibility verified before the visit. Patient balance expectations set at scheduling. A billing company can recover denials, but it cannot recover a claim that was never submitted because the chart was never signed. And on the other side: complete ownership of denial follow-up, a report a physician can read, and problems raised before they compound. THE SHARED VALUE EQUATION Dream Outcome. Practice: defines it specifically and measurably upfront. Billing partner: maps a realistic written path to it before the contract is signed. Perceived Likelihood. Practice: consistent operational inputs, charts closed, front desk disciplined, patient balances engaged. Billing partner: track record, transparent reporting, accountability on their own performance. Time Delay. Practice: patience through the 90 to 180 day ramp and commitment to the agreed timeline. Billing partner: weekly visibility, a clear map of the transition, no black boxes. Effort and Sacrifice. Practice: willingness to change what needs changing on their side of the operating model. Billing partner: making their side of the change as easy as possible and owning it completely. THREE ACTIONS THIS WEEK 1. Write down three to five specific, measurable targets that would tell you the relationship is working. Denial rate. AR days. Net collection rate. Chart closure rate. Clean claim rate. 2. Ask any prospective partner for before-and-after data from three practices in your specialty at a similar volume, and ask to speak with them directly. 3. Get the month one, month two, month three ramp in writing before the relationship starts, and reference it at every monthly review. EPISODE BREAKDOWN The switch that made things worse | The value equation and why every variable has two sides | Dream Outcome | Perceived Likelihood | Time Delay and the honest ramp | Effort and Sacrifice | Three things to do this week Resources block 1. FREE: EMR / PM Evaluation Framework, https://eligibility.natrevmd.com/emp/pm-evaluation-framework 2. FREE: Practice Revenue Leak Scorecard, https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3 3. Everything else we have built, in one place: https://natrevmd.com/trusted-resources/ 4. Referenced in this episode: $100M Offers by Alex Hormozi 5. Part 2 of this series, EP201 The Shared Operating Model: https://natrevmd.com/podcast/ 

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Send us Fan MailThere is a revenue cliff hiding inside the billing transition most independent practices are planning right now. Not from the change itself. From the order of it. In this episode we walk through why the money in your bank account during month one of a new billing arrangement is almost entirely old AR, why simultaneous service and software change is the fastest way to lose that money, and the three questions you have to answer before any sequencing decision makes sense. Three questions before you sequence anything: Are you replacing an in-house team or an outsourced vendor? Who owns the software? Is the software working, or is it part of the problem? Skipping these is where the error gets made. System 1: The revenue ramp. Month one is 80 to 90 percent old AR. Month four is 95 to 100 percent new team. Every sequencing decision has to protect that ramp. System 2: In-house vs outsourced risk profiles. In-house transitions risk institutional knowledge walking out. Outsourced-to-outsourced transitions risk data access and credentialing. Different risks, different sequences. System 3: Three software paths. Keep functional software and transition service only. Replace failing software after service stabilizes. Or defer the outdated-but-functional software conversation until months four through six. Three actions this week Answer the three questions in writing before any vendor conversation. Pull your AR aging report. If more than one month of gross charges sits past 45 days, plan an AR cleanup sprint before the new team starts. Read your current vendor or software contract for data provisions, notice terms, and auto-renewal windows. Episode breakdown 00:00  Hook and big idea 02:30  The three questions 13:00  System 1: the revenue ramp 16:00  System 2: in-house vs outsourced 20:00  System 3: three software paths 24:00  Summary and action plan 26:00  CTA and cliffhanger Resources EMR / PM Software Assessment Form (primary): https://eligibility.natrevmd.com/emp/pm-evaluation-frameworkBook a Revenue Audit: natrevmd.com/schedule-a-call Payment Posting Audit Checklist: eligibility.natrevmd.com/payment-posting-checklist Practice Revenue Leak Scorecard: eligibility.natrevmd.com/nrm-revenue-scorecard-v3 30-Day Revenue Recovery Plan: eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan 

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Send us Fan MailFREE — SEE WHERE YOUR PRACTICE IS BLEEDING REVENUE IN 3 MINUTES Take the RECOVER Diagnostic Quiz: https://eligibility.natrevmd.com/recover-quiz-lp More free resources: https://natrevmd.com/trusted-resources/ Payment Posting Audit Checklist: https://eligibility.natrevmd.com/payment-posting-checklistWE ARE RE-AIRING THIS EPISODE BECAUSE IT MATTERS RIGHT NOW. On July 1, 2026, the Medicare GLP-1 Bridge went live. Every independent practice with Medicare patients on Wegovy, Zepbound KwikPen, or Foundayo for weight management is now facing retrospective prior authorizations routed through a central processor most billing teams have never worked with. The AMA released physician guidance on June 26. The workflow is new. The documentation burden is heavier than most practices have modeled. And prior auth was already the fastest-growing revenue threat independent practices face. In this episode Dr. Heather walks through: WHAT WE COVER Why prior auth denials are silently eating clinical time and revenue The dollar amount your practice is losing every month (and how to calculate it) The 5-step workflow to manage prior auth without drowning your team What every practice needs to change this week "Prior auth has a dollar amount attached to it. Most practices never calculate it." THREE ACTIONS THIS WEEK 1. Calculate what prior auth is costing your practice in staff hours, denied claims, and clinical time 2. Set up a central prior auth tracker (do not run this out of email threads) 3. Train the team on the Medicare GLP-1 Bridge central processor workflow before the backlog compounds

Send us Fan MailA household runs on clarity, not effort. So does a practice. Most performance problems in independent practices are clarity problems: somebody thought somebody else was handling it. This episode builds the RACI model (Responsible, Accountable, Consulted, Informed) into your billing workflow and your hiring. What RACI actually means.  Four roles, each assigned to a person for a task, with one hard rule: never more than one Accountable person. If two people are accountable, nobody is. Mapping RACI to your practice.  A denial slips through when the billing manager assumes the front desk verified eligibility and the front desk assumes the billing manager caught it at scrubbing. With RACI, every role is named and the gap disappears. An unowned weekly denial review at a $350K-a-month practice can run 3 to 5 percent above its potential clean claim rate, $10,500 to $17,500 a month lost in a gap nobody owned. Hiring into the RACI structure.  Define the RACI role before the job description. A person wired to execute will struggle in an Accountable seat that requires sitting with ambiguity. That is a role mismatch, not a character flaw.Three actions this week Map the RACI for your weekly denial review (if you cannot name the Accountable person in thirty seconds, the task has no owner). Audit your current team against the RACI role definitions: right role, right wiring? Use RACI in your next hire, before you write the job description. Resources 30-Day Revenue Recovery Plan (primary): eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan Book a call with Heather: calendly.com/heather-natrevmd Payment Posting Audit Checklist (supporting): eligibility.natrevmd.com/payment-posting-checklist Referenced: The Five Dysfunctions of a Team by Patrick Lencioni; High Output Management by Andy Grove. 

Send us Fan MailQ1 2027 cash flow crisis. That is what is waiting for every OB practice that does not have a plan in motion by October. Not because the codes are hard. Because the time ran out to prepare for them. Knowing what is changing and being ready for it are two completely different things. In the OB Global Coding Series finale, Dr. Heather Signorelli walks through the exact ninety-day month-by-month plan to be ready on January 1, 2027 — payer contracts in July, EHR templates and workflows in August, provider training and shadow audits in September, refinement through Q4. Month 1 · July · Payer contracts: Your contracts reference specific CPT codes. When 59400 and 59510 disappear January 1, those contracted rates disappear with them. Identify your top five payers by maternity volume. Reach out to each provider rep with a written timeline question. Model your current revenue per episode before negotiating. Use the ACOG payer advocacy toolkit. Submit written notice of intent to renegotiate before July 31 to get into the Q4 queue. Month 2 · August · EHR + workflows: Systems first, people second. Rebuild prenatal, postpartum (inpatient and outpatient), and labor management templates. The labor management templates are built from scratch since 59080 – 59083 have no legacy. Build the multi-provider attribution protocol, the same-day postpartum hard stop, and the modifier TH automation. Month 3 · September · Provider training + shadow audits: Mandatory training for all clinical staff. Show providers their own notes and the dollar difference between what they wrote and what they could have written. Run shadow audits monthly: twenty prenatal notes, ten labor management, ten postpartum rounding. Track results by provider. Brief the front desk on the patient-facing talking points. September 1 is the ACOG testing date — NOT a payer compliance deadline. Submit test claims to your top three payers and watch what comes back. Q4 · Refinement, not crisis: October: follow up with payers for written fee schedule confirmations. November: CMS finalizes RVUs — update your revenue model with real numbers. December: billing team readiness check. January 1: go live. The practices that did the Q3 work transition smoothly. The ones that did not are scrambling. The reframe: The elimination of the global OB codes is not a threat to your practice. It is a correction. OB/GYN has been undercompensated for the complexity of maternity care for thirty years. That ends January 2027, if you are prepared.RESOURCES BLOCK Save your seat: Live OB/GYN Global Codes Update Webinar (July 7, 2026, 4:00 PM ET) · eligibility.natrevmd.com/obgyn-global-updates-webinar Book a 1:1 with Dr. Signorelli · calendly.com/heather-natrevmd/ Full series playlist: EP188 · EP189 · EP190 · EP191 · EP192 (https://natrevmd.com/podcast/#) Practice Revenue Leak Scorecard · eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Payment Posting Audit Checklist · eligibility.natrevmd.com/payment-posting-checklist RECOVER Diagnostic Quiz · natrevmd.com/quiz 

Send us Fan MailDeliver at 11 PM Tuesday and round at 1 AM Wednesday: paid. Deliver at 8 AM Tuesday and round at 4 PM Tuesday: included in the delivery code, and billing it separately is a compliance violation. Same clinical work, two different outcomes. The only variable is the calendar. Starting January 1, 2027 postpartum care moves to E/M billing with hospital rounds, discharge management, and outpatient checkups all individually billable. Dr. Heather Signorelli walks through the code sets, the same-day trap, the multi-provider wrinkle, and the three-step workflow that catches it every time. The end of the postpartum bundle: Code 59430 (postpartum care only) is deleted January 1, 2027. All postpartum care moves to E/M billing. Two settings, two code sets: inpatient (hospital rounds) and outpatient (office visits). Inpatient postpartum codes: Subsequent hospital care: 99231, 99232, 99233 for daily rounding visits after the date of delivery. Discharge day management: 99238 (30 minutes or less) or 99239 (over 30 minutes). Every rounding day after delivery, on a new calendar date, is a separately billable E/M encounter. Documentation has to support the level. A one-liner does not support a 99233. Outpatient postpartum codes (with telehealth correction): Standard office E/M: 99212 through 99215 with modifier TH. Telehealth uses the same 99212 through 99215 codes with modifier 95 or GT, and place of service 02 or 10. There is no separate “98000” telehealth code set, contrary to earlier references in this series. Modifier TH on all postpartum E/M codes communicates the maternity context to the payer. The same-day rule: Postpartum E/M codes CANNOT be reported on the same calendar date as the delivery code. Same-day postpartum management is included in the delivery code. Calendar date means midnight to midnight, not twenty-four hours from delivery time. The multi-provider wrinkle: If Dr. Smith delivers at 8 AM and Dr. Jones rounds at 4 PM the same day, Dr. Jones cannot bill an E/M for that visit. The delivery code covers same-day postpartum regardless of which provider from the same group performs it. This requires an internal compensation and attribution policy, not just a billing rule. The workflow fix — three steps: Timestamp discipline on every delivery and rounding note Billing team hard stop: verify delivery date before dropping any postpartum E/M charge Daily L and D reconciliation: track delivery date, rounding date, and provider by patient, daily The revenue opportunity: Every hospital rounding day after the delivery date is a new billable E/M. Extended stays from complications (postpartum hemorrhage, severe preeclampsia, wound infection, NICU situations) all generate additional charges. Complexity matters for reimbursement. Outpatient two-week and six-week checks are now individually billable instead of absorbed into a global fee. The same-day rule is the risk. Everything after midnight is the opportunity. Quick Reference Table:Topic                                                                             What to knowDeleted postpartum code                            59430 — deleted Jan 1, 2027 Inpatient rounds                                             99231 – 99233 Discharge codes                                                      99238 (≤30 min) · 99239 (>30 min)Outpatient postpartum                                 99212 – 99215 + modifier TH Telehealth modifier                                        Modifier 95 or GT · POS 02 or 10                                                                             NOT a separate 98000     code set Same-day rule                                                           Postpartum E/M cannot be billed on the                                                                              same calendar date as the delivery Calendar definition                                        Midnight to midnight Multi-provider same-day                                    Delivery code covers regardless of                                                                                       which group provider roundsWorkflow fix                                                    Timestamps · billing hard stop · daily                                                                                    reconciliationRESOURCES BLOCK Save your seat: Live OB/GYN Global Codes Update Webinar (July 7, 2026, 4:00 PM ET) · eligibility.natrevmd.com/obgyn-global-updates-webinar Book a 1:1 with Dr. Signorelli · calendly.com/heather-natrevmd/ Practice Revenue Leak Scorecard · eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Payment Posting Audit Checklist · eligibility.natrevmd.com/payment-posting-checklist RECOVER Diagnostic Quiz · natrevmd.com/quiz Series Part 3 (EP191): https://podcasts.apple.com/us/podcast/191-labor-management-is-no-longer-invisible/id1624182351?i=1000775009191

Send us Fan MailUnder the global model, labor management was absorbed into the delivery code. Two hours or twenty-two, same payment. Starting January 1, 2027, the AMA introduces 59080 through 59083, the first dedicated labor management codes in CPT history. The work was always there. Now it gets paid. Dr. Heather Signorelli and Amy Hicks, CPC, COBGC, our AVP of Operations, walk through the codes, the documentation, the corrected delivery code framing, the midnight-spanning labor rule, the multi-provider attribution problem, and the three actions every OB practice should take this quarter. Why labor management was invisible: Under the global model, the cognitive work of managing labor was absorbed into the delivery code. Practices managing complicated labors (preeclampsia, GDM, category two tracings) have been subsidizing simple deliveries for decades. The four new labor management codes: 59080 (initial day, straightforward) · 59081 (initial day, complex) · 59082 (subsequent day, straightforward) · 59083 (subsequent day, complex). Codes bill per calendar date. One code per date per patient. Straightforward vs complex: the six-criteria test: All six straightforward criteria must be met: singleton vertex, routine monitoring, no FHR intervention required on that date, normal progression or routine induction without complication, stable medical conditions, no prior cesarean. Any one criterion not met means the labor is complex. Duration of labor alone is NOT complexity unless prolonged labor is formally diagnosed. What the complex note has to say: Explicitly name the complicating condition. Not just “patient has GDM,” but what about the GDM you managed today. Document MDM across multiple data sources, labs reviewed, monitoring strip interpreted, imaging assessed. Document additional monitoring or intervention beyond standard, what you did and why. Document multi-provider coordination if applicable that date. For 59083 (subsequent day complex), complexity must be re-established for EACH subsequent day. A single admission note does not carry forward. Delivery codes (corrected framing): The 2027 delivery codes separate vaginal from cesarean, not vaginal from operative. 59431 (vaginal, no prior cesarean) · 59432 (VBAC vaginal) · 59502 (primary cesarean) · 59503 (repeat cesarean). Vacuum and forceps are separately billable add-on procedures. Included in the delivery code: placenta, first and second degree laceration repair, same-day postpartum care. Separately billable add-ons: 59433 (third degree lac), 59434 (fourth degree lac), 59623 (uterine tamponade, new 2027 code), 59504 (hysterectomy with cesarean). Midnight-spanning labor (correcting the record): A continuous labor encounter spanning midnight is reported as ONE labor management service on ONE of the two calendar dates. The practice decides which date. Inpatient E/M codes (99221 through 99236) do NOT stack with labor management codes. They replace each other. Inpatient E/M applies before labor begins. Once active labor management starts, switch to 59080 through 59083. Multi-provider attribution: Each provider bills the service they personally performed. The labor management code goes to the provider who managed labor on that calendar date. The delivery code goes to the provider who delivered. If the delivering provider also managed labor on the delivery date, they can bill both. Two failure modes: the miss (no one drops the charge), and the double-bill (both providers drop the same charge). The solution is a daily reconciliation, not monthly. Three actions this quarter: Map your call and cross-coverage. Find where charges go unbilled today and where two providers could overlap. Build a daily L and D reconciliation process. Assign ownership. Reconcile before shift end, not at month end. Update EHR labor management templates to prompt for the six criteria, complicating conditions, MDM elements, and same-day decisions.  RESOURCES BLOCK Save your seat: Live OB/GYN Global Codes Update Webinar (July 7, 2026, 4:00 PM ET) · eligibility.natrevmd.com/obgyn-global-updates-webinar Book a 1:1 with Dr. Signorelli · calendly.com/heather-natrevmd/ Practice Revenue Leak Scorecard · eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Payment Posting Audit Checklist · eligibility.natrevmd.com/payment-posting-checklist RECOVER Diagnostic Quiz · natrevmd.com/quiz Series Part 2 (EP190): https://podcasts.apple.com/us/podcast/190-every-prenatal-visit-is-now-a-billable-event/id1624182351?i=1000774328121                                             

Send us Fan MailStarting January 1, 2027 every antepartum visit becomes its own billable E/M charge. The global OB code goes away. The seventeen deleted codes include 59400, 59510, 59425, and 59426. And the way most prenatal notes are written today supports a 99212 at best, even when the visit was genuinely a 99214. Dr. Heather Signorelli and Maria Reynoso, Director of RCM at NatRevMD, walk through what changes, what the notes have to say, and the three actions every OB practice should take this week. What changes January 1, 2027: Antepartum-only codes (59425, 59426) and global OB codes (59400, 59510) are deleted. Every prenatal visit is now a standard E/M visit with modifier TH. New patient 99202–99205. Established patient 99211–99215. What the notes actually look like today: Notes have been written for speed because the global model did not reward note detail. A typical 16-week prenatal note (BP, fundal height, FHTs, “patient doing well, return in 4 weeks”) supports a 99212. The provider did much more during that visit. None of it is in the note. Under 2027, that gap is real revenue. What a 99214 note has to say: ACOG's position: pregnancy is a chronic illness with exacerbation and progression for E/M purposes. The complexity is built in. The note has to reflect it. For a 99214, document the ongoing management of the pregnancy as a condition, the data reviewed with your interpretation, and moderate risk decisions like prescription management or monitoring a condition that could escalate. “Anatomy scan reviewed, normal” is a 99212. “Anatomy scan reviewed, normal four-chamber heart, no CNS abnormality, EFW consistent with dates, AFI normal, counseled patient” is a 99214. High-risk patients finally pay for the complexity of their care: Under the global model the complex patient and the low-risk patient paid the same. The new model fixes that two ways. Complex visits code at a higher level (99214 / 99215). And more frequent visits equal more claims. For 99215 the note needs the specific complicating diagnosis named, data reviewed with interpretation, the management decision and the reason behind it, and specialist coordination if applicable. Same-day procedures and modifier 25: Antepartum procedures (NSTs, ultrasounds, amniocentesis, CVS) still bill separately. The E/M visit on the same day is now also billable with modifier 25. The note must independently support the E/M, not just the procedure. Three actions this week: Audit twenty random prenatal notes against the 2021 E/M guidelines to set your baseline Rebuild EHR templates to prompt for MDM elements, not for speed Start documentation training in Q3, using providers' own notes side by side with the corrected version and the dollar difference Quick Reference Table:       Topic                                                                                    What to knowDeleted codes count                     -      17 codes deleted total Antepartum-only codes                  -       59425, 59426 — deleted Jan 1, 2027Global OB codes                                  -       59400, 59510 — deleted Jan 1, 2027 New patient E/M range                    -       99202–99205 + modifier TH Established patient E/M range    -       99211–99215 + modifier TH 99214 vs 99213                              -       ~$46 per visit at Medicare ratesModifier 25               -       On the E/M when a procedure is also billed same dayACOG test date         -September 1, 2026 — recommended start for test claimsRVU finalization       - CMS proposes July 2026, finalizes November 2026 RESOURCES BLOCK Save your seat: Live OB/GYN Global Codes Update Webinar (July 7, 2026, 4:00 PM ET) · eligibility.natrevmd.com/obgyn-global-updates-webinar Book a 1:1 with Dr. Signorelli · calendly.com/heather-natrevmd/ Practice Revenue Leak Scorecard · eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Payment Posting Audit Checklist · eligibility.natrevmd.com/payment-posting-checklist RECOVER Diagnostic Quiz · natrevmd.com/quiz Series Part 1 (EP188): https://podcasts.apple.com/us/podcast/188-17-ob-codes-just-got-deleted-your-real-deadline/id1624182351?i=1000773393336Coming next: EP191 · Phase 2 labor management codes (the codes that have never existed in CPT before) 

Send us Fan MailShow notes A physician built a solid, growing independent practice over six years, then got bored with the pace and chased three new ideas at once. None launched. The original practice still lost an estimated $180,000 in revenue degradation over twelve months, not from a bad decision, but from the boring work quietly going undone. This episode is the framework for staying in the room with it. The compounding cost of distraction.  The revenue cycle does not tolerate divided attention. When leadership focus drifts, performance does not collapse, it leaks. A $350K-a-month practice that drifts for six months can lose $84,000 in net collections that never gets recovered. The shiny idea did not cost the money. The distraction did. The patience advantage.  A boring denial-rate fix that recovers $8,000 to $12,000 a month compounds every month forward. A new service line that might add $5,000 a month creates complexity with no compounding. Patient money picks the boring fix every time. The boredom threshold.  James Clear calls boredom the greatest threat to success. When the practice is working, the work stops feeling like progress and starts feeling like maintenance. The reframe: the boring work is not maintenance, it is compounding. The Five Shiny Objects That Cost Practices the Most The Shiny Object   Adding a second location before ops are solid Switching EMR mid-growth Launching a new service line Hiring aggressively before systems exist Chasing a new payer vertical What It Feels Like Growth and scale Modernizing and streamlining Diversification and new revenue Team building and capacity Revenue diversification What It Actually Costs 2x overhead, fragmented leadership, billing gaps at both sites 6 to 12 months of workflow disruption, revenue dip during transition Core service attention drops, existing margin erodes Payroll grows faster than revenue, management overwhelm follows Credentialing lag, cash flow gap, billing team stretched thin Three actions this week Name the hard problem you have been avoiding, and write it down. Calculate what one boring fix is worth over twelve months (a 3% net collection lift on $300K a month is $108,000 a year). Schedule the boring meeting that keeps getting skipped: weekly, named owner, standing agenda. Resources 30-Day Revenue Recovery Plan (primary): eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan Book a call with Heather: calendly.com/heather-natrevmd Payment Posting Audit Checklist (supporting): eligibility.natrevmd.com/payment-posting-checklist Referenced: Atomic Habits by James Clear.

Send us Fan MailShow notes On January 1, 2027, every global OB code your practice has billed for the last thirty years is being deleted. Seventeen CPT codes. Gone. Replaced with a completely new structure for how every dollar of maternity revenue is earned, attributed, and collected. And the real deadline for your practice is not January 1, 2027. The real deadline is right now. What is actually going away For over thirty years, OB practices have lived in a bundled global world: one patient, one pregnancy, one code. Effective January 1, 2027, 17 global obstetric CPT codes (including 59400 for a global vaginal delivery and 59510 for a global C-section) are being deleted entirely. The AMA and ACOG determined the global model no longer reflects modern OB standard of care, and so the structure is being fully replaced, not patched. The four new phases of maternity billing Phase 1, Antepartum care. All bundled antepartum codes deleted. Every prenatal visit billed as individual E/M with TH modifier (99202 through 99215). Phase 2, Labor management. New dedicated code category for the first time in CPT history. Reported per calendar day, with straightforward vs complex management distinction. Phase 3, Delivery. Vaginal vs cesarean restructured. VBAC coded differently than first-time vaginal. Add-on procedures (3rd/4th degree laceration repair, uterine tamponade) now separately billable. Phase 4, Postpartum care. All existing postpartum codes deleted. Hospital care codes for inpatient day-after-delivery. Office E/M for outpatient follow-up. Same-date postpartum bundled into delivery. Why the real deadline is Q3 and Q4 2026 Cash flow in January 2027 will be decided this Q3 and Q4. Payer contracts reference CPT codes by number, so contracts that reference deleted codes need renegotiation now. Documentation habits have to change before the new codes go live, because every prenatal visit now needs to support E/M level selection. A 200-patient OB practice undercoding prenatal visits by even $40 each is leaving close to $100,000 a year on the table from day one. The multi-provider attribution problem Under the global model, attribution was easy: one practice, one fee, regardless of which provider saw which visit. Under the new model, every encounter is attributed to the individual provider who performed it. Practices with midlevels, hospitalists, or shared call need a clear protocol for labor management billing, on-call coverage, and cross-coverage now, or they will either double-bill (compliance risk) or miss charges (phantom revenue) from day one. Three actions this week Pull a payer contract audit. List every commercial contract referencing global OB codes that needs renegotiation before January 1. Run a prenatal documentation review. Pull 10 recent prenatal charts per provider and assess them against current 99213 and 99214 E/M standards. The gap is your single biggest revenue risk. Map your provider attribution workflow. Write out exactly how labor management, on-call coverage, cross-coverage, and same-day postpartum care will be tracked when every encounter is attributed individually. Episode breakdown 1. The 17 deleted codes 2. The four new phases of maternity billing 3. Why Q3 and Q4 of this year is your real deadline 4. The multi-provider attribution gap 5. What patients will see on their EOBs 6. Your 90-day action plan 7. What is ahead in the rest of the OB Global Coding Series Resources → Live OB Global Updates Webinar (PRIMARY): eligibility.natrevmd.com/obgyn-global-updates-webinar → Book a call with Heather: calendly.com/heather-natrevmd → Payment Posting Audit Checklist: eligibility.natrevmd.com/payment-posting-checklist → Practice Revenue Leak Scorecard: eligibility.natrevmd.com/nrm-revenue-scorecard-v3 → Coming next in the series: EP189 — How to Bill Antepartum Care Under the New E/M Model 

Show Notes Your fee schedule is a revenue ceiling. And for most independent practices doing over $3 million a year, that ceiling is set too low in ways that never generate a denial and never appear on a standard report. EP186 covers the five gaps that are quietly capping your revenue, the exact fix for each one, and three actions to run this week. Gap 1 — Billing Below Your Own Allowables: You negotiate a better payer contract. The billing system does not get updated. The payer pays what you billed, not what you are owed. A practice with 20 high-volume CPT codes averaging a $10 billing gap across 800 monthly claims is losing $8,000 a month, $96,000 a year, from a contract they already won. Gap 2 — Inconsistent Fee Schedules Across Locations: A secondary location runs on its legacy fee schedule from before acquisition. Location A bills $210 for a procedure. Location B bills $165 for the same code. A site doing 400 visits a month with a $35 average billing gap is under-billing $14,000 a month, $168,000 a year. Gap 3 — No Medicare Multiplier Anchor: Fees set by instinct drift downward every year while costs move in the opposite direction. The fix: anchor to 200–300% of the current Medicare allowable and recalculate every November when CMS publishes updated rates. Gap 4 — Suppressing Global Fees for Self-Pay Patients: A practice protecting 15% self-pay volume by keeping fees low inadvertently discounts 100% of encounters. 850 commercial patients billed $40 below the correct rate: $34,000 a month, $408,000 a year. The fix: raise the global fee schedule and implement a separate documented sliding fee scale for uninsured patients. Gap 5 — No Annual Fee Schedule Review: A fee schedule that is right in year one becomes the revenue leak of year five. A $4 million practice drifting 3% below where it should be loses $120,000 a year in collectible revenue. Over five years: $600,000. The Five Fee Schedule Gaps at a Glance: Billing below allowable → Payer pays billed charge, no alert → up to $8K/month Location fee inconsistency → Lower site appears compliant on reports → $3K–$15K/month No Medicare multiplier anchor → Fees drift, no logical update trigger → Compounds annually Artificially low global fee → Self-pay policy masks commercial discount loss → $5K–$20K/month No annual review → Costs rise, billed charges flat → 3–5% margin erosion per year Three actions this week: Run the top-20 CPT code comparison — billed charge vs. highest commercial contract allowable Anchor your fee schedule to the Medicare multiplier — recalculate for this year Put the annual fee schedule review on the Q4 calendar today — first week of November, billing manager named as owner Episode breakdown: 00:00 The fee schedule is a revenue ceiling 02:30 Why silence in billing costs more than denials 05:00 Gap 1: Billing below your own allowables 09:00 Gap 2: Inconsistent fee schedules across locations 13:00 Gap 3: No Medicare multiplier anchor 17:00 Gap 4: Suppressing global fees for self-pay patients 21:30 Gap 5: No annual fee schedule review 25:00 Three actions this week 29:00 Free resource + EP187 tease Resources Mentioned NEW LEAD MAGNET  Primary resource this episode: 30-Day Revenue Recovery Plan. Payment Posting Audit Checklist is tertiary. 30-Day Revenue Recovery Plan (free): eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan Book a free 30-minute call: calendly.com/heather-natrevmd Practice Revenue Leak Scorecard (free): eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Payment Posting Audit Checklist (tertiary): eligibility.natrevmd.com/payment-posting-checklist CMS Medicare Physician Fee Schedule: cms.gov (updated annually each November) 

Most practice owners think their billing problem is a billing problem. It usually is not. The denial showing up this month started 60 days ago at the front desk. In this episode, Dr. Heather Signorelli sits down with Josh Sauter, President and CEO of Staffing First, to unpack why hiring is the first domino in your billing cycle, what it costs you when that domino falls, and how to think about staffing and revenue cycle as one connected system instead of two separate problems. SEGMENTS The first domino Josh's core insight: the front desk is where the billing cycle actually begins. A bad fit, a thin onboarding, or a missed training step upstream creates downstream denials 30, 60, 90 days later. The denials almost always look like a billing problem. They almost never are. The 30/60/90 day lag Why billing problems usually trace back to hiring decisions made a quarter ago. The eligibility check that did not happen on day 30 is the denial that lands on day 60 and the cash flow gap on day 90. The hire-slow trap Why saving money on staffing costs more in the long run. The wage gap pushing practices to underhire is the same wage gap pushing candidates out within the first year. Josh's view after 17 years: cheap hires are the most expensive line item in a practice. Coordinating front office and billing What it actually takes to make sure front desk failures do not kill claim throughput downstream. Weekly huddles between front office, billing lead, and the practice manager. Clear escalation paths for eligibility failures and payer changes. A billing partner that flags denial patterns back upstream instead of just working the claims. What a real staffing partner does differently Josh's process: 10 to 12 candidates interviewed for every order, top 2 to 3 sent to the practice. Deep questions about culture and not just skill. Behavioral health background applied to candidate screening. The practice manager gets the time back that they were burning on bad-fit interviews. REFERENCE TABLE: THE 30/60/90 DAY FRONT DESK LAG Timeline  | What happens upstream  | Where it shows up Day 0  | New front office hire, undertrained or wrong cultural fit  | Looks fine on the surface Day 30  | Eligibility checks missed, demographics keyed wrong, payer changes not caught  | First denials start landing Day 60  | Patterns compound, claim rework volume rises, missed authorizations stack  | AR over 60 starts climbing Day 90  | Practice blames the billing department  | Billing partner gets fired and replaced, problem persists THREE ACTIONS THIS WEEK Pull your last 90 days of denials and tag every one that traces back to front office (eligibility, demographics, missing authorization). Patterns will reveal hiring or training gaps before they hit Q3 cash. Run one weekly 15-minute huddle between front office, billing lead, and practice manager. Cover the top three denial reasons that week. Every week. Book a 1:1 with Heather to map the front desk to billing handoff in your practice: calendly.com/heather-natrevmd/ RESOURCES 1. Book a 1:1 with Heather Signorelli, MD: calendly.com/heather-natrevmd/ 2. The 30-Day Revenue Recovery Plan: eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan 3. Talk to Josh Sauter at Staffing First: staffingfirst.net  |  jsauter@staffingfirst.net 4. Practice Revenue Leak Scorecard: eligibility.natrevmd.com/nrm-revenue-scorecard-v3 5. Payment Posting Audit Checklist: eligibility.natrevmd.com/payment-posting-checklist 6. RECOVER Diagnostic Quiz: natrevmd.com/quiz

Most independent practice owners know the practice and their personal life are supposed to be separate. Separate entities, separate accounts, separate tax returns. Almost none of them have built the structural separation that makes that true when things get hard. EP185 covers the three systems that explain why one bad quarter in the practice becomes a personal financial event, and the firewall that stops it. System 1 — The Entanglement: No formal salary. No distribution schedule. Whatever is left in the business account goes home with the owner. In a good month: $40,000. Mortgage, 529, investment contribution. In a bad month: $14,000, covered with personal savings. The savings account does not come back as fast as the practice does. System 2 — The Bad Quarter Multiplier: The cascade that runs from a billing disruption straight through to the owner's personal financial decisions. Collections drop. Distribution skipped. Mortgage still goes out. Investment contribution paused. Operational decisions made under financial stress — delay the hire, pull back on marketing, hold off on the software upgrade that would have fixed the billing gap that caused the problem. That practice is always one bad quarter away from making decisions a wealthier version of itself would never make. The Cascade in Numbers: Payer delays 45+ days → Operating account drops → Owner stops paying themselves first Denial rate spikes 5% to 14% → $28K/month delayed or lost → Personal savings tapped for household bills Key provider unexpected leave → Volume drops 30% → No distribution for 60 days Contract renegotiation stalls → 90 days cash flow uncertainty → Investment contributions paused indefinitely System 3 — The Firewall: A market-rate owner salary that does not move with revenue. A distribution schedule tied to net profit after a defined reserve threshold. Personal savings that build independent of what the practice has on hand. In a bad quarter: the salary still goes out, the distribution pauses, and the operational decisions come from strategy instead of personal financial pressure. Referenced: Profit First by Mike Michalowicz — the formula flip that makes the firewall mechanical. Three actions this week: Calculate your real owner salary — what you would pay someone else to do your job Define your operating reserve threshold — one month of payroll minimum, two months standard Schedule a financial separation review with your accountant — ask what a 30% revenue drop does to your personal finances Episode breakdown: 00:00 The $380K practice that one quarter turns 03:00 The big idea: revenue is not wealth 06:00 System 1: The Entanglement 10:30 Working vs. broken — the same practice, two outcomes 13:30 System 2: The Bad Quarter Multiplier 17:00 The cascade and what it actually costs 20:00 System 3: The Firewall 24:30 Profit First applied to a medical practice 27:00 Three actions this week 31:00 Free resource + EP185 tease Resources Mentioned Payment Posting Audit Checklist (free): eligibility.natrevmd.com/payment-posting-checklist Practice Revenue Leak Scorecard (free): eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Book a free 30-minute audit call: calendly.com/heather-natrevmd RECOVER Diagnostic Quiz: natrevmd.com/quiz Book referenced: Profit First by Mike Michalowicz 

Independent practices rarely lose money because the medicine is wrong. They lose it because the highest-paid person is buried in clerical work and the front desk is too deep in daily chaos to chase eligibility, fill cancelled slots, or collect patient balances. We sat down with Tim Boyle of Reva Global Medical to talk about medically trained virtual assistants, and where the recovered revenue actually comes from. The front-end gap Scheduling, eligibility, verification, and prior authorization are the number-one denial categories. A front-desk team in the middle of ringing phones and walk-ins cannot also run the strategic prep that prevents those denials. A dedicated VA can, and that is usually the first seat to delegate. The no-show math A practice can run 20% open availability from no-shows. Without someone working a waitlist to fill those slots, that is overhead the practice simply eats. A VA reaching out the day before, and pulling from a call list when a slot opens, both lifts the patient experience and recovers revenue. The back-end gap Statements go out, but nobody works them. A trained VA handles patient-balance collections and the AR backlog, using HIPAA-certified propensity-to-pay tools to make a genuinely hard conversation go as well as it can for the patient. Who not how Heather and Tim land on the same idea the most successful owners share: protect your zone of genius and delegate the rest. The framing comes from Who Not How by Dan Sullivan and Dr. Benjamin Hardy. Clerical work is the low-hanging fruit, and the first thing to hand off. How the right VA is hired Reva accepts roughly 5% of applicants. The practice interviews finalists one-on-one with Reva's camera off, so the owner chooses who joins the team. SOPs are set up first, a client services manager reports daily or weekly, and the practice does not pay until the VA is trained and working. THREE ACTIONS THIS WEEK Download the 30-Day Revenue Recovery Plan and start working it from day one this week. Pull your no-show rate for last month and multiply it by your average visit value. That is your waitlist opportunity. List the three clerical tasks eating your day that do not require a clinician. That is your first delegation. EPISODE BREAKDOWN Tim's path from pro hockey to healthcare sales Why revenue leaks at the front desk Letting go of control as a practice owner The hiring and training process (the 5% filter) Who Not How and your zone of genius Back-end collections and the tough patient conversation What it costs and what comes back RESOURCES30-Day Revenue Recovery Plan — eligibility.natrevmd.com/nrc/-30day-revenue-recovery-plan Book a Call with Heather — calendly.com/heather-natrevmd Payment Posting Audit Checklist — eligibility.natrevmd.com/payment-posting-checklist Practice Revenue Leak Scorecard — eligibility.natrevmd.com/nrm-revenue-scorecard-v3 RECOVER Diagnostic Quiz — natrevmd.com/quiz Reva Global Medical — revaglobalmedical.com  |  Tim Boyle — Tim@revaglobalmedical.com Book referenced: Who Not How by Dan Sullivan and Dr. Benjamin Hardy 

Part 2 of our multi-location revenue series. If you haven't listened to Part 1 (EP182) yet, start there — the systems in this episode build directly on what we covered last week. EP182: Click hereToday we cover the two structural problems that let the Part 1 gaps stay open: front-end data inconsistency across sites, and the one role that either holds a multi-site practice together or lets it fall apart. System 3 — The EHR and Billing Disconnect: Different front desks develop different habits. One site verifies eligibility morning-of. The other verifies the day before. One collects copay at check-in. The other sends a statement after. A practice doing $120,000/month at Location B with a 20% authorization miss rate sends $24,000/month into billing with incomplete data. Some claims get caught in scrubbing. Some get denied. Some sit in a gray zone no one can explain at month-end review. Front-End Gap Reference: Authorization not captured → Denial or recoupment post-payment Insurance not updated at visit → Claim sent to wrong payer Copay not collected at check-in → Patient AR that rarely converts Eligibility verified day-of only → Coverage lapses missed pre-visit System 4 — The Office Manager Problem at Scale: Location A has a strong office manager who has been there since the beginning. Location B has whoever was available when the site opened. The metrics look similar on paper. The difference shows up in the denial rate, days in AR, authorization miss rate, and the number of times the billing manager has to fix something that should have been caught at the front desk. A $90,000/month site with an underperforming office manager loses an estimated $8,000 to $15,000/month in avoidable billing delays. That is $180,000/year from one seat filled with the wrong person. Three actions this week: Audit front-end protocol consistency — pull authorization miss rate and eligibility verification rate by site Run a site-level office manager assessment — KPIs only, not by feel Schedule weekly site-level KPI reviews — separate meetings, not consolidated Episode breakdown: 00:00 Series callback: the gap the report will not show you 02:00 The thread left open in Part 1 04:30 System 3: The EHR and Billing Disconnect Across Sites 08:00 The $24,000/month authorization miss scenario 11:30 Who owns the front-end protocol fix 14:00 System 4: The Office Manager Problem at Scale 18:30 The $180,000/year gap from one wrong seat 22:00 Who owns the accountability structure 24:30 Three actions this week 28:00 Free resource + next episode tease Resources Mentioned Payment Posting Audit Checklist (free): eligibility.natrevmd.com/payment-posting-checklist Practice Revenue Leak Scorecard (free): eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Book a free 30-minute audit call: calendly.com/heather-natrevmd RECOVER Diagnostic Quiz: natrevmd.com/quiz EP182 — Part 1 of this series: Link here

You opened a second location because the first one was working. What no one told you: the moment you added that second site, you added a second set of revenue gaps. And most of them are invisible on a consolidated report. In Part 1, we cover the two most expensive gaps inside multi-location practices doing over $300,000 a month. Neither generates a single denial. They just show up as missing revenue no one can explain. System 1 — The Credentialing Gap: A provider sees patients at a new site before credentialing is finalized. The claims go out. The payer rejects them, or pays provisionally and recoups months later. One provider, 60 uncredentialed days, 15 patients per day at $180 per visit: $162,000 in claims at risk. The front desk who scheduled those patients had no idea. System 2 — The Shared Billing Problem: One billing team covers both locations. Denials get triaged by volume, not by site. The smaller location falls behind. Its AR days climb past 40, then 50. Six months of recoverable claims cross the timely filing window. A secondary site at $90,000/month with a 12% denial rate instead of the target 5% loses $6,300/month in unworked denials. Over a year: $75,600. That is the gap the report will not show you on a consolidated view. Three actions this week: Build your credentialing matrix (one row per provider, one column per location, effective dates visible) Pull a site-specific AR report — not consolidated, by site Set a site-level denial threshold and define what triggers an immediate review meeting Episode breakdown: 00:00 The revenue gap no consolidated report will show you 02:00 Why multi-location growth is a systems problem 04:30 System 1: The Credentialing Gap 09:00 The $162,000 scenario 12:00 Who owns the credentialing matrix 14:30 System 2: The Shared Billing Problem 18:00 The $75,600/year site-level loss 21:00 Who owns the site-specific AR report 23:30 Three actions this week 27:00 Free resource + Part 2 preview Credentialing Scenario Reference: 1 provider | 60 days | 15 pts/day | $180/visit = $162,000 at risk 2 providers | 30 days | 12 pts/day | $200/visit = $144,000 at risk 1 provider | 90 days | 10 pts/day | $150/visit = $135,000 at risk Resources Mentioned: Payment Posting Audit Checklist (free): eligibility.natrevmd.com/payment-posting-checklist Practice Revenue Leak Scorecard (free): eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Book a free 30-minute audit call: calendly.com/heather-natrevmd RECOVER Diagnostic Quiz: natrevmd.com/quiz 

If you stepped away from your practice for 30 days, what would happen to your revenue? If the honest answer is "it would fall apart" — you don't have a scalable practice. You have a high-paying job with employees. In this episode, Dr. Heather Signorelli breaks down the four forms of leverage that separate practices that grow on their own from the ones that only move when you show up. The Leverage Framework: Form 1 — Capital Leverage: why it's the highest-risk, lowest-compounding form Form 2 — Labor Leverage: why 10x headcount creates 10x management complexity Form 3 — Code/AI Leverage: what $15K–$25K/month in avoidable billing losses actually looks like Form 4 — Media Leverage: the one asset that compounds while you sleep The Lion Sprint Framework: why sprinting beats grinding — and what your three sprints are this week Episode breakdown: 00:00 Opening question: what happens if you step away? 02:30 Leveraged vs. un-leveraged — the real 2026 divide 05:00 Form 1: Capital Leverage 08:00 Form 2: Labor Leverage 11:00 Form 3: Code/AI Leverage 14:30 Form 4: Media Leverage 18:00 The Lion Sprint Framework 20:30 Sprint 1: Policy Sprint (Media Leverage) 22:30 Sprint 2: Chart Closure Sprint (Code + Labor Leverage) 24:30 Sprint 3: Eligibility Training Sprint (Labor + Media Leverage) 27:00 Free resource + payer rule change teaseResources Mentioned Payment Posting Audit Checklist (free): eligibility.natrevmd.com/payment-posting-checklist Practice Revenue Leak Scorecard (free): eligibility.natrevmd.com/nrm-revenue-scorecard-v3 Book a free 30-minute audit call: calendly.com/heather-natrevmd RECOVER Diagnostic Quiz: natrevmd.com/quiz 

The difference between practices that scale and practices that stall is not clinical skill. It is operational structure. And most practices doing $250K to $500K a month have already outgrown theirs. In this episode, Dr. Heather Signorelli breaks down the three root causes of operational chaos that keep growing practices stuck at a revenue ceiling they cannot break through. You will learn: Why ambiguity in roles costs you hard dollars in denied claims How running your revenue cycle on memory puts your cash flow at risk every single day Why unsigned charts are delaying tens of thousands in billing every month Three things you can do this week to assess exactly where you stand This is Part 1 of 2. Part 2 delivers the exact accountability chart structure, daily checklist templates, and provider productivity metrics to fix what Part 1 diagnoses. 

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 

What if the biggest revenue leak in your practice isn't a denial or a payer contract problem - it's the person processing your payments? In this episode, Dr. Heather Signorelli breaks down the four-step payment posting audit we run on every practice we onboard - and why practices doing $300K+ a month are routinely losing $8,000 to $25,000 of it to undetected posting errors. You'll learn: • How to catch unapplied patient payments before they generate angry calls • The ERA spot check that exposes systemic contractual adjustment errors • How to find payer underpayments before your billing team writes them off • The write-off audit that protects your revenue from unauthorized adjustments This is the final episode in our four-part payment posting series. If you've been following along, you now have more visibility into your revenue cycle than most practice owners ever get.

When your patient AR report shows thousands in past-due balances, it's easy to blame high deductibles. But a lot of that money is already in your bank account sitting unapplied—or it's a phantom balance the patient never actually owed. In this episode (Part 3 of our Payment Posting series) we walk through the four patient payment posting mistakes that inflate AR and damage patient trust: Unapplied patient credits — money in your bank, AR still open, patient gets billed again Payer denials shifted to patients by mistake — poster doesn't read the ERA denial code, patient gets a statement for money they don't owe Co-insurance misposted as a flat copay — wrong payment code at check-in, ledger breaks when the claim processes Unauthorized write-offs — billers clearing their queue by wiping balances with no authorization or audit trail Each mistake has a fix you can implement this week. 

Your AR report says hundreds of thousands of dollars are coming in. But if your team is making these four insurance posting mistakes, a significant portion of that AR is phantom money that was never going to be collected. In this episode (Part 2 of our Payment Posting series) we walk through the four insurance-side mistakes that inflate AR and drain revenue: Ignoring contractual adjustments — the gap between billed and allowed sits in AR as uncollectible phantom money Accepting underpayments as paid in full — payer shorts you on a contracted rate, poster writes off the difference without flagging it Leaving zero-balance claims open — fully paid claims clogging your AR and inflating your workload Duplicate posting — same ERA payment posted twice, creating phantom credits and balance chaos Each mistake has a fix you can implement this week. 

There's a number in your practice that looks precise but lies to you every single month: your AR report. We routinely audit multi-provider practices showing $400K, $600K, even $1M in AR — and 20–40% of that “asset” is already dead. Not collectible. Just trash left behind by bad payment posting. In this episode — the first in a 4-part series on payment posting — Heather walks through what payment posting actually is, why getting it wrong silently inflates your AR, and the seven specific things that change in your practice when posting is done right. Inside the episode: Why your AR report is a mirror of your team's posting accuracy, not what you're actually owed How a $400K/month practice dropped their AR by 30% in two weeks — without collecting a dollar more The 7 reasons clean payment posting transforms your revenue cycle The audit moment we found 200+ accounts a week being reworked that were already paid in full What's coming in Episode 176: the most common insurance-side posting mistake we see in almost every audit If you're a practice owner, billing lead, or operations director who has ever made a financial decision off an AR report — this is the foundation. Resources mentioned (Buzzsprout episode resources block) 

Your CPA sends a P&L on the 20th of every month showing a positive bottom line. Then tax season hits — or partners ask for a distribution — and the cash isn't in the bank. Sound familiar? This episode breaks down why standard P&Ls fail private practices doing $150K+/month, and how to replace them with a live financial dashboard that tells you the truth in real time. RESOURCES MENTIONED IN THIS EPISODE

Resources mentioned Practice Revenue Leak Scorecard (free, ~60 seconds): https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3Book a call with our team: https://natrevmd.com/contact/Visit us: natrevmd.com Are your patient volumes climbing but your bank deposits flatlining? That's one of the most terrifying patterns in private practice  and the scariest part? Your reports might not show any of it. In this episode, we break down the 3 early warning signs that your billing is broken and give you a clear, actionable plan to diagnose the problem before it becomes a six-figure issue. If you're running an independent medical practice doing $250K+ a month, this is the gut check you need. What we cover Warning Sign #1: AR over 90 days creeping above 15–20% — and why your team might be "statussing" claims instead of resolving them Warning Sign #2: Lack of transparency from your billing team (in-house or outsourced) — what to ask for, and what their answer tells you Warning Sign #3: Receipts dropping while charges stay stable — the two most common causes A real example from a practice we work with — credentialing holds and why pulling the data first matters Your 3-step action plan to run this week Chapters (00:00) Charges up, deposits flat: the signal most owners miss (01:30) Free Practice Revenue Leak Scorecard (02:15) Warning Sign #1: AR >90 days (04:30) Warning Sign #2: Lack of transparency from your billing team (06:30) Warning Sign #3: Receipts drop while charges stay stable (08:30) Recap: the 3 key takeaways (09:30) Your 3-step action plan this week (11:30) Book a free revenue audit About NatRevMD We're a physician-led medical billing and revenue cycle management company built for independent medical practices. Founded by Dr. Heather Signorelli, we help private practices stop revenue leaks, fix broken billing operations, and protect their margins. 

If your practice has anywhere from $50,000 to $500,000 sitting in the 120+ day Accounts Receivable bucket, we have bad news: most of it isn't coming back. And the reason isn't what your billers are telling you. Old AR is rarely a payer problem. It's an accountability problem. We recently took over the AR for a multi-specialty group whose 120+ bucket had ballooned past $300,000. We didn't find complex coding disputes. We found unresolved eligibility issues, missing EOBs sitting on payer portals, ignored write-offs, and billers who were "statussing" claims instead of actually working them. In this episode, we break down the 6 real reasons claims go to die — and the top 3 strategic oversight actions you must put in place today to hold your billing team accountable and stop the bleeding. Stop guessing about your financial health. Take our free 60-second Practice Revenue Leak Scorecard to see exactly how much revenue your practice is leaving on the table: https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3 

Resources mentioned in this episode: Free Practice Revenue Leak Scorecard: https://eligibility.natrevmd.com/nrm-revenue-scorecard-v3?hs_preview=hUmAzejh-210981640602  Subscribe on YouTube: https://youtube.com/@natrevmd  Join the conversation: https://natrevmd.com/community  Are you staring at a billing report that says your collection rate is 98%... but your bank account tells a completely different story? If you're running a practice doing over $250,000 a month, relying on surface-level billing reports is the fastest way to lose hundreds of thousands of dollars a year without even realizing it. In this episode, we're talking about revenue leaks. Not the obvious ones. The invisible ones. We break down the three biggest lies your standard AR reports are telling you, and exactly where to look to find the missing money today 

Free Resources Mentioned in This Episode: Get your personalized score of where your practice is losing revenue. Free Revenue Diagnostic Quiz — Find Your Biggest Billing Leaks in 60 Seconds —  get a personalized score showing exactly where your practice is losing revenue.  Are you an independent medical practice owner doing over $5M a year, but you feel like you have to oversee everything to get anything done right?  If your front desk is missing copays and your billing team is letting claims sit for months, you don't have a personnel problem—you have a process problem.  In this episode of NatRevMD, we break down the exact 5 Standard Operating Procedures (SOPs) you need to build unbreakable accountability in your practice.  Learn how to transition from managing people to managing processes with one-page SOPs for eligibility verification, financial scripts, claim submission, scorecard reviews, and clinical documentation. Stop putting out fires and start scaling your practice today. 

Thinking about outsourcing your medical billing? Before you make a decision, you need to listen to this episode. We hear the same three fears from practice owners every single day: "It's going to be too much work to transition," "It's going to cost too much," and "What if the next team is just as bad as my current team?" In this episode, we break down those fears honestly. We aren't here to pitch you — we're here to give you a decision guide. We cover the exact signs that tell you your practice is ready to outsource, and just as importantly, the 3 signs that you are not ready to make the switch.  If you are an OB/GYN or Urgent Care practice owner who is tired of guessing about your revenue, this episode will help you decide if an RCM partner is the right next step for your growth. We cover: The real math behind the cost of an in-house biller vs. an outsourced team What a successful transition actually looks like (hint: you shouldn't be doing the heavy lifting) Why having a strong Office Manager is the #1 requirement for outsourcing success The 3 operational red flags that mean you should keep your billing in-house  Free Practice Resources: Download the Free Eligibility Verification Guide: https://natrevmd.com/eligibility-billing-verification/ Get the 2026 Margin Protection Playbook: https://natrevmd.com/margin-playbook Want to see if you qualify for a billing metric audit? Check us out here: https://natrevmd.com 

If you feel like you have to have your hands in every single part of your practice just to make sure things get done right, you don't have a staffing problem. You have a systems problem. In Part 1 of this two-part series, we break down three specific, high-yield frameworks you can implement in your practice right now to build unbreakable accountability and eliminate micromanagement forever.  We cover: Why your org chart is useless, and how to build an Accountability Chart insteadThe exact 5-15 numbers that need to be on your weekly KPI Scorecard (with industry benchmarks)How to delegate effectively using the "Who Not How" framework Resources mentioned in this episode: Traction by Gino Wickman Who Not How by Dan Sullivan Free Eligibility Verification Guide: https://natrevmd.com/eligibility-billing-verification/ 2026 Margin Protection Playbook: https://natrevmd.com/margin-playbook 

Are you afraid to switch billing companies because you don't want the pain of a transition? Or worse, are you worried the next team will be just as bad as the last? Most practices that come to us aren't failing—they are just leaving money on the table. But the pain of unknown or lost revenue doesn't get better on its own.  In this episode, we pull back the curtain and show you exactly what it looks like to partner with NatRevMD. From our 2-to-4-week onboarding process and daily payment posting, to why we manage denials to the root cause instead of just "statusing" them.  We also share why we don't work with everyone—and why your front office is the key to unlocking a 20-30% revenue increase. Resources Mentioned: 2026 Margin Protection Playbook Free Eligibility and Billing Verification Guide Complimentary Billing Metric Audit 

Every practice faces operational hurdles—from complex coding rules to clunky EMRs. But for a high-volume clinic, these everyday challenges can quietly add up to a six-figure revenue gap by year-end. In this episode, we break down common billing pain points that impact your bottom line. We explore typical front office and billing hurdles—like cautious undercoding, unauthorized write-offs, and building true AR accountability—and share actionable ways to empower your team and safeguard your revenue. Resources Mentioned: 2026 Margin Protection Playbook Free Eligibility and Billing Verification Guide Complimentary Billing Metric Audit 

Resources Mentioned: Free Eligibility Checker 2026 Margin Protection Playbook You know how to practice medicine. But do you know how to get paid for it? The gap between your clinical work and the codes on a claim is where most practices lose revenue. This episode is for you. We translate 10 common clinical scenarios into the language of billing. Learn how your documentation for prescription management, injections, and high-acuity visits directly impacts your practice's revenue. This is a practical guide for clinicians who want to understand the "why" behind the codes and confidently capture the full value of their work.