High-Performance Practice Series, Ep. 5: Is Your Biller Keeping You Broke?

High-Performance Practice Series, Ep. 5: Is Your Biller Keeping You Broke?

A quick heads up for all the audience, if you've been tuning in to the show for a while, you know that it took me at least ten years of grinding in my own clinics before I finally figured out how to scale and sell my 4 practices for 7 figures, and about 3 times the national average. The biggest shift wasn't some secret marketing hack. It was how I thought about profit, systems and my role as the owner. That's exactly what we're going to be working on together with you at the High-Performance Practice Conference in San Antonio, Texas from October 15th-17th.

Adam Robin and I are hosting a three-day hands-on event for PT, OT, speech, mental health, peds, pelvic floor, and medical practice owners who want to build clinics that are profitable, scalable, and best of all, don't depend on them 24/7. We’ll dig into simple profit and KPI frameworks, real leadership and culture work and practical systems you can take home and plug in with your team.

If you're doing roughly 6 to 7 low figures a year and you want your client to feel more like a real business and less like a job/cage, I'd love to see you there. Frankly, I'd love to see you bring your leadership teams as well because we will have breakout sessions for them, too. You can get all the details and grab your seat at the link. Let's get into our episode.

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How are you doing?

Good. I'm grateful to be here.

You seem more energized.

I'm practicing gratitude and all that stuff.

It doesn't look like a forced smile, so you do have a little bit more energy.

Possibility and gratitude are what I'm choosing. That's the season I'm in.

For those who have been following us and joining us, we're on episode five of the High-Performance Practice series, all leading up to the High-Performance Practice Conference in October 2026. Our third annual Private Practice Owners Club Conference is going to be in San Antonio, from October 15th-17th, 2026. Go to PPOClubEvents.com.

We're going to do amazing things at this conference. It is different from last conferences, with breakouts and people outside of the industry coming and talking to us in terms of speakers. We're going to have opportunities for your leadership teams who join you and that you bring to divide and conquer. You get more value out of it so you can train up your leadership teams as well and provide them value. Check out PPOClubEvents.com. That is the High-Performance Practice Conference.

In this episode, the last time we spoke about negotiating contracts, payer relationships, and stuff like that, in the same vein, the idea behind being a high-performance practice is to make it as profitable and as efficient as possible to develop freedom and some of the visions and goals that you have as an owner. Managing billers is a unique topic that I've talked about occasionally on the show. It's one that could be a pain in the butt when billing's not going well, like the front desk.

The front desk can be a huge pain in the butt if it's not going well. It affects so many other things downstream. When you're talking about billers, you could do a ton of good work, see all the visits, get your marketing right in line, and charge well, but then if your billers aren't doing well on the backend, it's all for naught.

You're still broke.

You could easily go broke no matter how well you're performing your therapy services. I frequently say it. That's a weak spot for owners. Would you feel like that was an uncomfortable place for you to oversee, manage, and supervise your billing team? You've always outsourced them, but did you have to go through that as well, where you were like, “I want them to tell me what's going on instead of me owning and supervising them?”

Ignorance is the most expensive tax you pay. We're all ignorant, especially in the beginning. We get, hopefully, a little less ignorant every year. To answer your question, yes. At the beginning, you don't know what the heck you're doing.

You're relying on them, like, “They're the experts. They're going to tell me what to do and what's going on.” You're like, “Go ahead.” You think it's all passive and things are going to go well.

Stop Treating Billing Like A Passive Task

I've never had that strategy work, ever. You can get lucky every now and then. If you have that one rock star, whether it's a biller or an employee, that was a great bet. Usually, that's not the case. The big majority of that is not going to be the case. I have said this many times before. Things never got better until I got better.

The first step in getting better is understanding. The first stage is the education or the orientation stage. You've got to know what good looks like, so that you can ask the right questions, hire the right people, and hold a good standard. Until you know that, until you're in that place of knowingness, you're going to be in the dark a little bit.

I went through all the billing situations for over a decade before I finally landed on a decent biller myself. It wasn't that I knew how to suddenly manage them. It finally became a situation where I had the person in front of me. I hadn't asked this from my bills before, but I told her, “You need to teach me how to read these reports, know what good is, and what to expect out of you.” Since I had the right person, she would train me because she had plenty of experience before. Prior to that time, we had done our billing in-house most of the time. She could bring up the reports.

Establish Monthly Meetings With Clear Agendas

I was getting serious, like, “We need to have, number one, monthly meetings. We're going to have some back and forth during the month. We are going to have a scheduled sit-down meeting where we wrap up the previous month. We look over the previous month and what went well, what went wrong, where you spent your time, where you are having hiccups, what we can expect in the upcoming month, and where you are going to put your energies.”

We did monthly meetings with an agenda. This is an opportunity. I've shared plenty of times before for them to report to you. When you had your initial billing company, and you outsourced most of your ownership, what was the default setting in terms of communication? Was it they'd send you an email with the report’s kind of thing, or have you always had a relationship such that they wanted to meet with you?

For the first biller, we had a monthly meeting, but I didn't run that meeting.

They said, “Here's what's going on.”

That’s right. I was like, “We're good.” What do they say? The person with all the knowledge gets all the money. They had all the knowledge. I was completely out-leveraged in that relationship. I had no control over the outcome or direction of my company. I saw Jeff Bezos one time. He said, “If you don't understand the details of your business, you're going to get smoked.” I didn't know the details. I saw some numbers, and I was like, “What does this even mean?” The one thing that triggered the first red flag was that I saw the AR number getting a little bit bigger every month.

On the AR aging report?

That’s right. I was like, “What is that?”

You were like, “That keeps going up.”

I was like, “Is that good? Is that bad? What does that mean?” I started getting things like, “This is pretty standard. This is how it always was.” That's the point where I started working with you, and you were like, “That's not good. That's bad.” I was like, “What do you mean by that?” That was my journey. I had to learn from Nathan. That's how I got hooked up with Will and In the Black. They did a great job. That was the first time that I was like, “This is what good looks like.” Becoming a student of that revenue cycle changed.

I looked back, and I was going to ask you the same thing, but how much money did we lose for billers? They could easily say hundreds of thousands of dollars over the decade-plus that I didn't have good billers. It's hard to swallow. For those of you who are reading, it is worth a lot of money to get control and management over your billers so that you are competent and start to work now so you don't lose any more in the future.

Number one is having an agenda. It’s like, “These are the reports that we need to go over.” I don't know about you, but we would review purpose and values. These were in-house employees. They're going to review our purpose and values as we do every other meeting. We talk about that and where we can improve.

We talk about calendar items coming up and who's going out of town. If a bill is leaving, what do we do in the meantime? We go over the reports. We would go over what was projected versus what was collected. We go over the denial rates and where the denials are coming from. We'd look over AR aging reports as a whole and by payer.

Track Your Primary Financial KPIs

Some billers will present dates of service outstanding metrics. I didn't lean into that all too much. I understand it, but that wasn't an important one for me. I wanted to see those three that I mentioned. What were your collections versus expected? What was the first pass denial rate and AR aging? Does that sound about right for you? Is that what you're looking at?

It's exactly what I think. The main principle that matters there is that you have a meeting, you have some metrics, and you're discussing them and having some expectations around what the minimum expectation is around each of them. You're not expecting perfection. You're expecting that when things do happen, because they will. We are putting all of our talents and resources into fixing it and bringing it back into a place of stability.

Nobody is going to create that environment except for the owner. You're the person with the standard. You have to create that standard. Managing your biller is no different than managing any other employee in your team. It's the basic fundamentals of HR and organizational structure. Ideally, have an agreement. Have some type of job description for them with some expectations, some policies and procedures in place, some KPIs, and a meeting rhythm for accountability. You've got to bring that to the table.

That's whether they're in-house or outsourced. They've got to understand your expectations in terms of communications.

Correct. Outside of that, become a student of the revenue cycle. You’re like, “What does that mean? How does that work? Can you break that down for me exactly? Why is that important to me?” These are the types of questions you should be asking so that you can understand how the whole revenue cycle works.

As you were sharing your story, some of those red flags are, “This is very normal. We expected this. You don't need to worry about that. We're going to take care of it.” Those would be red flags for me. I want answers. As we're going into this meeting, you're having a great experience with the biller that you're working with.

The reason I gather that you're happy with them is that they saw the problem in the reports before you did, and they had solutions for those problems before you even asked. When you did ask, or if they didn't already present them when you did ask, it’s like, “We saw it, too. This is our plan X, Y, and Z. This is how we're going to knock it out. These are the communications that we've already had about it. We're waiting for a response.”

They're not coming to the meeting looking at those reports for the first time with you. I'm expecting they have gone through those reports with you. They know the metrics and their KPIs. They know where they fall short. They know where they did well. They know exactly what the comments, notes, and communication levels are for the issues, especially the outstanding balances that are large. I expect them to be coming with answers. None of those should be the first time that they see it.

There should be a level of intensity in a meeting, I believe. Don't be too intense, but this is business. I'm expecting us to have a level of focus and seriousness around the problems we're trying to solve here. If you're at a meeting with your biller and they're like, “Everything's fine. Everything's good,” and it's too casual. You should be like, “Why aren't you urgent? You're dealing with health insurance. Surely, there's some type of problem that we could be solving.”

These are numbers. We need to get serious. To break down some of these metrics a little bit more, I'll go into that, but I’ll add one more thing. If you're not collecting payments at the time of service or automatically charging credit cards on file for outstanding patient balances, reviewing the patient AR balances would be another thing to add to the agenda. We have maybe 4 or 5 items to go over the agenda.

To break it down, first, we're looking at projected versus collected. We know what to project. We're sitting in August 2026. We're looking at July numbers. The projected collections for July are usually the visits in June time. Your average reimbursement per visit is what would be collected in July. Did you hit that metric? It's not going to be perfect, but you should be within 5% to 10%. I know you like to be closer to 5%.

If it's close to 10%, then maybe there's some reason why we had a hiccup with X, Y, and Z Insurance Company. It should approximate that. Secondly, we're looking at the denial rate. If there was one cardinal marker and you didn't want to look at anything else, maybe the first pass denial rate should be less than 10%. I know you want less than 5%. You want single digits.

I want it cleaned up.

Third, you're looking at the AR aging reports. The benchmarks we're expecting our billers to hit in that. Eighty percent of your outstanding AR being in the 0 to 60 range. Five percent, 60 to 90. Five percent, 90 to 120. Ten percent, 120 and above. We would see some motor vehicle accidents. Some people call that no-fault, personal injury, or whatever. Those balances usually are 2 to 3 years old, so we usually exclude those from these numbers.

In excluding those numbers, this is what things should look like in your AR aging report. You can break that down by payer because some payers are going to have some hiccups. That's when you break it down, and you're like, “Blue Cross Blue Shield is having a hard time. There's a lot of stuff out there in 120 and above. What's going on?” If your billers are keeping acceptable ranges in those three things, wouldn't you assume they're doing pretty dang well?

Treat Denial Rates As Your Leading Indicator

Totally. I think so. I always look at the denial rate as the leading metric. If your denials are high, it's going to bleed into your AR. I don't even like to rely on my average reimbursement per visit metric unless my denial rate is at a good rate. If it's high, then I can't go off of my projection cleanly. I always think about cleaning in-house first.

Your billing department, traditionally, the way that I've always thought about it is everything that happens after the claim has been sent. That may or may not be true. It’s debatable. That’s the way that I think about it. The denial rate is going to be the entry level to how clean that's happening. How do we drive denials down? All of that happens inside the clinic. That's on you.

That's training stuff.

That's on the owner. That's on the front desk. That has to be buttoned up. You can't blame your biller if your denial rates are 15%. That's on you, or at least your biller needs to be holding you accountable.

There has to be some communication from the biller side. The biller should know that KPI and say, “Our denial rate is at 18%. I need to come in, sit in on lunch, and train you guys on what's getting denied and why.” It could be the front desk. It could be the providers. It could be the whole team. They need to be proactive about correcting that number.

Clean Up Front Desk Intake To Protect Billing

We need clean and accurate insurance verification and patient demographic information at the front desk. It has to be cleaned up. If you don't put the dot after the middle name, it's going to get denied. That's number one. Number two, you need your codes from the provider side scrubbed appropriately. Make sure that they're only using the codes that are approved by each insurance type.

You didn't know, “With this insurance, I can't bill 97140. It's going to be denied.” There needs to be training on that.

You should be able to clean that up. Lastly, the authorization side. Make sure that your authorizations are filed on time and cleaned up. If you do those things well, your denial rates are going to be low. If you talk to anybody in the revenue cycle, they're going to say, “Start on the front end of the revenue cycle. Start on those three things. Those are the most important things.”

Things go so much smoother on the backend.

From there, you can have a more predictable average reimbursement per visit metric.

I see it.

You can start projecting month to month. Your denial rate is going to be your day-to-day. Your projections will be your month-to-month. That should be closer to 100%. Your AR can be more quarter-by-quarter. If you have one bad month, your AR is probably not going to take a huge shift. If you have a bad quarter, that AR is going to start looking rough.

That's the way that I think about it. Here's the thing. If your denials are high, your biller is going to submit five claims. Next month, one of them is going to come back denied. I have to submit five more claims. Plus, I've got to work on this denial. Next month, there's going to be another one that's denied. Now, there are two that are denied. I got 5 claims and 3 denials to manage. It can become administratively impossible to manage on the back end. It can be hard to keep up if your systems on the front end aren't.

Your example carries even more weight if you add some zeros. Fifty claims in one day and twenty get denied or tend to get denied, we're talking overwhelm.

It's a hairball, right?

Exactly.

That's why you need a good billing department.

It could also be a good outsourced biller. We unfortunately don't know how to manage them, especially when they're outsourced, because they usually come with five-star reviews. Other people have recommended them. They tout these great systems. They promote and market themselves as well.

You expect them to do the job and abdicate your responsibility instead of stepping into an ownership role of being in charge of your billing collections company or department, whether that's outsourced or in-house. It's important to have that mindset and that they work for you. Many times, when we abdicate that responsibility, we almost start feeling like, “I'm working for the billing company. I've got to get them the information that they need, so they get off my back.” Rather, you need to take control.

For those that are tuning in, there are a few pain points that you might be experiencing. If you're a smaller practice and maybe one location, you're going to struggle with profitability. If you don't have a good billing department, it's going to be chaotic. Your front desk is going to be overwhelmed. You're not going to be as profitable as you could be. You could lose like mega bucks. We're talking about like 5% or 10% profit margins from the revenue cycle.

You can also see it during growth phases. If you're trying to scale up and try to open up 2 or 3 more clinics, the volume that can start seeing inefficiencies at the front desk and at the back end becomes more critical for you to know how to do this stuff. If you're in that place of overwhelm, the good news is you don't have to learn it all in a day. It’s like anything else. Let's start with one thing at a time. If you can learn a little bit every month, study it, tune in to the show, and come to St. Antonio at the conference, you can become an owner who can create real change in those problems. That's going to be the real unlock. It is when you empower yourself to make that change.

We had some of this, and we were able to work around it fairly well. I heard about it from billing companies in the past. There tends to be friction between the billing collections team and the front desk. Have you experienced that situation?

Align Cultural Values Across Teams

I think it's a culture, like anything else. Culture is the lubrication that communication flows through. Making sure that you are working with a billing company or department that has aligned and that you have aligned people on your team is important. If you have a bunch of performers on your team, that is probably going to go away. If somebody is not taking accountability, that's the problem.

What we want is everybody to shut up and own something. Fix the problem. Let's get in problem-solving mode and not complaining mode. When I look back at times when that dynamic wasn't as ideal, it was usually because there was an expectation that we had of the billing company that they were dragging their feet, and my team was performing. It was rarely our fault. It could have also been like maybe you had a front desk person that wasn't owning the front end of that revenue cycle the way they should or could have. There could have been a transition that should have taken place there.

There are those front desk people that when you're trying to correct them, they take it personally. They get butthurt and defensive and start blaming. They need to understand that if there's a dropped authorization and that's your responsibility, that's on you. You can't blame that on the billing people. I'm glad that you brought up values because one thing that we're looking at when we're talking to billing companies is talking about values too much. Do these people align with our values?

They are going to be representing you when it comes to the patient interaction. If there's a patient outstanding balance, they're representing you. You would like them to have the same values as they approach those patients as you do when you approach the patients. Maybe there's an interview process with your billing company about, “How do you handle outstanding patient balances? Imagine I'm the patient and I owe $250. How are you going to talk to me when we're on the phone?” Honestly have those kinds of conversations.

If the front desk isn't getting some portion of the intake paperwork done, how do you expect that communication to go? Do you communicate directly with them? If it doesn't change, then who do you talk to? When do you get me involved? If I'm their supervisor, when do you get the supervisor team involved? Walk through some of those scenarios because you'd expect them to ideally align in values.

You can ask values-based questions without specifically labeling the value, like, “How do you practice integrity?” It doesn't necessarily have to be like that. One of the questions that I like to ask is, “How do we become the best client that you've ever had? What would that look like for you?” What you want them to describe is the characteristics that they value. It’s like, “Tell me about a time where you had a client that wasn't a good fit for you. What were some of the things that showed up that got under your skin that could have been better?”

What you'll find are the characteristics that they operate by typically. I've got a great company. If you guys want to know more information, send me an email, and I'll tell you who it is. When two rockstar people start working together, like a rockstar billing company and a rockstar person, there is a chemistry there that gets exciting. It's achievable. You've got to know what it looks like.

Things start flowing. There is palpable change in those meetings when you have the right people in tow. Anything you want to add to managing the biller conversation?

A quick wrap-up. What are the top 1 to 3 things that I would ask you as an owner that would help us understand if you have good control over your billing department? The first thing is, number one, “What are your key metrics? What are the key metrics that you're measuring that are driving decisions in your revenue cycle month over month?” If you can't answer that question, that doesn't mean you're a bad person. It means you're not buttoned up.

You need to know your numbers.

You need to know your numbers a little bit better. That answer is probably 90% of it. Number two, “How often do you meet with your billing department? What does your accountability rhythm look like? How do you know you have the right person in the right seat?” Answer those two, and then the last one would be, “Do you have a regular cadence of accurate insurance verification and authorization? Is there some type of department lead for those two buckets at the front desk or in the authorization department? Are they accountable to reporting something up with accuracy?” If the answer is no, then you probably need to button that up. Those three things will get you 95% of the way there.

I agree. It's an accountability meeting rhythm. Know your numbers. I see a common personality trait in the good billing teams that I've worked with. They are bulldogged when it comes to collecting money.

They're confident, too.

They're confident. They're not afraid to ask for money. They will make as many calls as they need to make. They are not shy. When they collect that last $21 check from United Healthcare that's been sitting out there for eighteen months, they are ready to party.

They're competitive.

Adopt A Firm Stance On Collections

Their mentality is us versus the insurance company.

It's value.

When it comes to the patient, they have empathy, but they’re like, “You owe this money because we did the work. This is your insurance, not ours. You chose the insurance that you have. You owe the balance. We did the work. You owe us the money.” They won't say it in those words, but they're not afraid to go after the money. They will trip over themselves so they can collect another $10. There's that kind of bulldogged mentality that permeates the good billers that I've had in the past.

Here's the cool thing. When they come to those accountability meetings, they're proud. They’re like, “We did some cool stuff this month. Look how well I'm doing.” They're like a Golden Retriever with their tail wagging, waiting to get petted. They’re excited about what's moving forward. When they're frustrated, they’re like, I hate that company. I'm going to get them.” They are tied up emotionally in their work in a good way.

I agree with all that. The other thing I'll add is if you're going to outsource, you want to work with a team that has good business acumen. What are the metrics that they track internally? How often do they meet as a company to talk about their values and to measure performance? They need to be good at business if they're going to be good for your business. If you've got a retired mom that's in her basement, we love her, and she’s a great person, but if you plan on scaling up practice, she might not be the best person to stick with long-term. They need to button up.

That's something that gets you off the ground. If you want to get somewhere, then you have to consider moving up, right?

Correct.

We will cover stuff like this at the conference. Go to PPOClubEvents.com. Check that out. It is the High-Performance Practice Conference. There is a worksheet tied to this. You can download a free worksheet to write down your notes. It's going to give you some questions on there to help inspire you a little bit to figure out what next steps could be as you're working with the particular topics that we're talking about. Check it out.

Check out the previous episodes. We've done four others thus far, and we've got a couple more. The next one is staffing ratios with clinical and admin teams. I'm sure we're going to talk about production in those departments as well. Our last episode, wrapping it up, is going to be cash-pay and out-of-network services. I know people are looking that direction quite a bit with reimbursement rates going down. Look forward to those episodes as well. In the meantime, register for the event at PPOClubEvents.com. We'll see you at the conference, and we look forward to seeing you in the next episode.

We’ll see you later.

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