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Most revenue leaks before the patient ever walks in. And billing usually gets the blame for problems the front desk could have prevented.

Dr. Heather Signorelli sits down with Alejandro (Alex) Fernandez, CEO of Synergy Orthopedic Specialists, a 25-physician, 60-provider orthopedic group with 15 sites across Southern California, including an ASC, imaging, physical therapy and DME. Alex started his career at a front desk in Miami more than 35 years ago, and he runs the business with that perspective: everyone in the practice is part of delivering care, and every role affects revenue.

FREE BILLING PERFORMANCE SCORECARD
https://eligibility.natrevmd.com/natrevmd-billing-performance-scorecard-actionable-plan
Enter six numbers from the system you already use and each one turns green, yellow or red, with a score out of 12, the dollar value of each yellow and red, and a one-page 90-day action plan.

TWO OR MORE REDS? FREE METRICS AUDIT REVIEW
https://eligibility.natrevmd.com/metrics-audit-natrevmd
Send us your monthly numbers and get a physician-led read on what the pattern is saying and where we would look first.

IN THIS EPISODE
- How to grow responsibly: start with your own data, test demand before you build, then execute small
- Why ancillary services you already refer out are often the easiest growth to add
- The front desk checks that protect revenue before the visit
- Why billing teams and the front desk need shared accountability, not separate blame
- How a 60-provider group is using AI today, and why Alex only buys AI that fixes a specific, measurable bottleneck
- Why you should fix your P&L and know your KPIs before adding complexity
- Grow from your strengths, not to escape a weakness

THE FRONT DESK CHECKS ALEX'S TEAM RELIES ON
- Verify eligibility 48 to 72 hours before the visit
- Scan the insurance card into the EHR so everyone can find it
- Confirm prior authorization, not just eligibility, especially for imaging, injections and surgery
- Collect everything owed at checkout, not just the copay at check-in
- Re-verify demographics for established patients every visit

HOW ALEX EVALUATES AI
- Imaging access: faster MRI scans mean more add-on patients without overbooking
- Phone answering: AI answers and books calls, with live operators one button away
- Training: policies, procedures and onboarding in one living playbook instead of a binder that is outdated the day it is printed
"Don't implement AI into a broken system. It will just break it faster."

THREE STEPS BEFORE YOU ADD A LOCATION OR SERVICE LINE
1. Look at your data: referral and zip code reports show where you send business out
2. Test the demand: sublease space from a non-competitor before you build
3. Execute small, and scale only once the test proves the need

CONNECT WITH ALEX
LinkedIn: https://www.linkedin.com/in/alexfernandezmba
Instagram, Facebook and YouTube: Alex Fernandez MBA

CONNECT WITH NATREVMD
Website: https://natrevmd.com
LinkedIn: https://www.linkedin.com/company/natrevmd/
YouTube: https://www.youtube.com/@NatRevMD

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Unhappy with your billing but afraid to switch? You are not the only practice in that middle. The numbers feel off, but a past transition (yours or a colleague's) meant months of slow cash, an overwhelmed front desk and frustrated providers. So you stay, and the cost shows up as a slow drift instead of one bad quarter.

In this solo episode, Dr. Heather Signorelli shows practice owners and managers how to tell whether billing is really the problem, how to improve it with the team you already have, and how to switch without losing money if the numbers say it is time. Decide from your numbers, not your nerves.

FREE BILLING PERFORMANCE SCORECARD
https://eligibility.natrevmd.com/natrevmd-billing-performance-scorecard-actionable-plan
Enter six numbers from your current system and each one turns green, yellow or red, with a score out of 12. You also get the dollar value of every yellow and red, a ready-to-send email asking your billing team for these numbers every month, and a one-page 90-day action plan. Nothing to switch.

TWO OR MORE REDS? FREE METRICS AUDIT REVIEW
https://eligibility.natrevmd.com/metrics-audit-natrevmd
Send us your monthly numbers and get a physician-led read on what the pattern is saying and where we would look first.

IN THIS EPISODE

•  Why billing transitions go wrong: the five places cash gets stuck (credentialing, ERA/EFT, charge lag, old A/R and people)
•  Why one strong month of collections is not proof of a healthy revenue cycle
•  The six numbers that tell you if your billing is working
•  How to improve billing without switching companies
•  What a safer transition looks like if you do switch
• -The two objections practices raise before a change

THE SIX NUMBERS (use a three-month average)

1. Net collection rate: Green 95%+ | Yellow 90 to 94% | Red under 90%
2. Denial rate (first submission): Green under 5% | Yellow 5 to 10% | Red over 10%
3. Insurance A/R over 90 (share of insurance A/R): Green under 10% | Yellow 10 to 15% | Red over 15%
4. Patient A/R over 90 (vs. 3 months ago): Green down | Yellow flat | Red up
5. Days in A/R: Green under 35 | Yellow 35 to 50 | Red over 50
6. Charge lag (date of service to claim sent): Green 3 days or less | Yellow 4 to 7 | Red over 7

Score: 2 points per green, 1 per yellow, 0 for red or unknown. Max 12. Two or more reds: get a second set of eyes before deciding anything. Ranges are working comparison points, not universal benchmarks.

IF YOU DO SWITCH: TRANSITION CHECKLIST
- Credentialing and payer enrollment confirmed for every provider, started first
- Software contract reviewed: who works old dates of service, and for how long
- Admin access to every payer portal held by the practice, with the list saved
- ERA and EFT routing mapped, first remittances verified
- Clean cutover by date of service
- Old A/R run as its own project, with an owner and a weekly report
- Front desk trained before go-live; short change list for providers
- A patient statement plan for old dates of service
- Charge lag and denial rate reviewed weekly for the first 90 days

THREE ACTIONS THIS WEEK
- Score your six numbers. Write "unknown" where you cannot get one.
- Send your billing company one email asking for the six numbers every month, with a three-month trend and the detail behind every red. The scorecard writes it for you.
- Pick your one or two biggest reds and put a 90-day review on the calendar.

COMPANION EPISODE
EP222: The $150,000 a Year Nobody Bills You For: Score Your Practice in 20 Minutes

CONNECT WITH NATREVMD
Website: https://natrevmd.com
LinkedIn: https://www.linkedin.com/company/natrevmd/
YouTube: https://www.youtube.com/@NatRevMD

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Most practices run on the bank balance and a sense of how busy things feel. In this working episode, Dr. Heather Signorelli takes your practice's vitals: seven numbers, four scored, about 20 minutes. Grab a pen. 

FREE RESOURCES 

Free Metrics Audit Review: send the seven monthly averages from this episode and get a physician-led read on what the pattern is saying and where to look first. https://eligibility.natrevmd.com/metrics-audit-natrevmd 

Practice Financial Health Dashboard: free Excel workbook that calculates and color-codes your KPIs every month, with 3-month and YTD trends. https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 

Everything we publish: https://natrevmd.com 

Claims and charges: the raw material. Claims are the denominator under almost every rate. Divide charges by claims and watch that average for silent charge-capture drops. 

Adjustments: where good numbers go to hide. Split contractual from everything else. If timely filing write-offs are coded as contractual, a 94 percent collection rate can look like 100. 

Net collection rate: receipts divided by charges minus contractual adjustments. About 95 percent is the common comparison point. A green you cannot verify is not a green yet. 

Denial rate: the front desk number everyone blames on billing. Use first-submission denials and keep rejections and prior auth denials out of it. 

Insurance A/R over 90: the money quietly becoming a write-off. Break it out by payer. One payer owning most of the old money is a payer problem, not a billing problem. 

Patient A/R over 90: scored on trend. The biggest factor is when you first tell the patient what they owe.  

Three actions this week: 

• Finish your scorecard with a three-month average. Write unknown where you cannot get a number. 

• Give your lowest vital one owner and one 30-day question. 

• Put the seven numbers on your monthly meeting agenda, same order, every month. 

Episode breakdown: The $150,000 nobody bills you for | Your practice's vitals | How the test works | Claims, charges, adjustments | Net collection rate | Denial rate | Insurance A/R over 90 | Patient A/R over 90 | Add it up | Your plan this week 

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Free resource: Practice Financial Health Dashboard for Physicians. 

What you get: a free Excel workbook built for physician owners to track the practice's revenue, expenses, and billing health month over month, in one place. → https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 

Free Metrics Audit: a free 20-minute live read of six numbers from your last full month (charges, claims, adjustments, denials, A/R, net collections) to find where revenue is leaking. No patient data, no system access. Built for practices collecting $150K or more a month. → https://eligibility.natrevmd.com/metrics-audit-natrevmd 

More from us: natrevmd.com 

Preston Alexander, Forward Slash / Health: https://forwardslashhealth.com | LinkedIn: https://www.linkedin.com/in/preston-alexander | The Healthcare Breakdown on Substack 

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Most practice owners check one financial number: the bank balance. Preston Alexander, writer of The Healthcare Breakdown, calls it management by bank account. In this conversation with Dr. Heather Signorelli, he explains why it keeps good practices one slow month away from the line of credit. 

Cash timing is the hidden problem. A practice that opens on February 2 should not expect meaningful insurance payments until April or May. Credentialing and billing setup take time, even for experienced teams. Practices that never planned for those months often spend years operating from behind. 

Revenue and expenses are one conversation. Billing metrics and the expense side usually live in separate places. Preston's team looks at CPT-level profitability, overhead allocation, and expense timing month by month so owners see the whole picture. 

Stable is not the same as healthy. Heather describes practices where billing is finally dialed in and payroll is still tight, usually because compensation was set before the revenue was forecast. Options include a smaller base with a bonus on what is left. 

The second location trap. A new address creates billing issues even under the same TIN, so Preston plans for about six months of near-zero revenue. Market fit matters just as much: referral patterns, the dominant health system, and payer mix. Heather adds that a drop from $175 to $140 revenue per visit changes what volume you need and what you can afford to spend. 

Three actions this week: 

• Pull your last 12 months of financials and ask why each line that grew went up 

• Ask one vendor you have paid on time for years for longer payment terms 

• Block one hour a week to review revenue and expenses side by side 

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Resources 

Free Metrics Audit: a free 20-minute live read of six numbers from your last full month (charges, claims, adjustments, denials, A/R, net collections) to find where revenue is leaking. No patient data, no system access. Built for practices collecting $150K or more a month. → https://eligibility.natrevmd.com/metrics-audit-natrevmd 

Practice Financial Health Dashboard for Physicians: a free Excel workbook built around the same six numbers, so you can track them month over month on your own. → https://eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 

More from us: natrevmd.com 

Coming soon: Our episodes with the CEO of a large independent practice and with an IPA leader

The end of September is the moment to start planning your first quarter of 2027. What you collect in January through March is mostly decided by what you do now. Dr. Heather Signorelli covers the five areas every owner, CEO, COO, or practice manager should review before the year closes. 

Your net collection rate. Gross collection rate compares what you collect to what you charge. Net collection rate removes contractual adjustments, so it shows what your team is writing off that it should be chasing: timely filing, bad debt, patient balances. Heather notes most practices sit in the mid to high 90s. Know your number and why it is where it is. 

A growth plan for 2027. Set revenue goals in the first week of October. Use this year's average reimbursement per visit (claims through June should be paid by now) to work out the patient volume you need, whether you need to hire, and whether services you refer out, like PT, subspecialty care, or lab work, have a business case to come in-house. 

Payer contracts. When did you last negotiate? Are any credentialing denials still open? Starting in October gives new rates the best chance of loading early. 

IPA options. An independent physician association can strengthen your contracting position, but there are good and bad ones. Look at who they serve, how fast claims get paid, quality metrics, and shared savings before you join. 

A coding audit. If it has been years, get one. Check levels, modifiers, and incident-to billing, and make sure your documentation supports the codes. OB practices in particular need to be ready for the 2027 code changes.

Three actions this week: 

• Pull your net collection rate and ask your billing team what is behind every non-contractual write-off 

• Put a two-hour 2027 planning session with your leadership team on the calendar for the first week of October 

• List every payer contract with the date it was last negotiated 

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Most practices don't have a billing problem. They have a not-knowing problem. Dr. Heather Signorelli walks through the three numbers that actually tell you whether your revenue cycle is healthy, and introduces the free Second Opinion Program built to give any practice an independent read. 

Denial Rate Isn't the Full Story: A five percent denial rate sounds fine until you ask why those denials are happening, and whether they cluster around one payer, one code family, or one provider. 

A/R Over 90 Days, Reported vs Real: “A/R is being worked” and “A/R is moving” are two different claims. Most owners only see the summary number, not the aging bucket broken out by payer. 

Payer Mix Trend: A quiet shift in payer mix shows up differently for patients (confusion about what they owe), front desk (more phone calls), and owners (a dip they can't explain three months later). 

Introducing the Second Opinion Program: A free, twenty-minute, physician-led review of these same numbers, independent of whoever currently handles a practice's billing. No pressure to switch, no disruption to the current team. 

Three Actions This Week 

•  Pull your denial rate by payer, not just the overall number, and ask why on the top two categories. 

•  Pull your real A/R aging over 90 days, broken out by payer, not the summary line. 

•  Compare this quarter's payer mix to last quarter's, and flag anything that moved more than a few points. 

Resources 

1. Book My Second Opinion →: eligibility.natrevmd.com/natrevmd-get-a-second-opinion 

2. Not ready to book? Free resources: natrevmd.com/trusted-resources 

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Dr. Una, founder of EntreMD and mentor to hundreds of physician entrepreneurs, joins Dr. Heather Signorelli to talk about what actually drives practice growth without burnout, and shares an unscripted story about why her own practice now trusts NatRevMD with its billing. 

Growth Problems Are Rarely About Billing: Dr. Una explains why the real lever for growth is almost always the evolution of the physician into the CEO of their own practice, not the team, the market, or the numbers themselves. 

Replace Yourself Three Times: Every practice owner plays three roles: technician, manager, and owner. Growth stalls hard the moment a physician replaces the technician role by hiring other providers but never replaces themselves as the manager. 

The Four Business Algorithms Every Physician Needs: Dr. Una walks through the four areas physicians have to learn like a clinical protocol: how to grow revenue, how to build a brand, how to fill the schedule, and how to build a genuinely profitable team. 

What Changes Past Five Million: At the five to ten million dollar mark, the game becomes about leadership across producers, managers, and leaders, plus obsessing over granular profitability data the way an ICU doctor watches vitals. 

You Cannot Resist Your Environment: Dr. Una explains why EntreMD is built on mentorship, accountability, and community rather than one-on-one coaching, including a real example of a client growing revenue 71 percent while taking eight weeks off. 

A Full Circle Story: Dr. Una's own practice switched its billing to NatRevMD after years of her practice administrator being unable to find a fit. Her verdict: “your billing department is your aorta. It is not a place you can afford to leak from.” 

Reference tables: None this episode. 

Three Actions This Week 

•  Write down the four numbers you are currently avoiding in your practice (AR, profit and loss, revenue per provider, schedule fill rate), and commit to reviewing them weekly. 

•  Name which of the three roles, technician, manager, or owner, you personally have not replaced yourself in yet, and pick one system or hire that starts that process. 

•  If nobody outside your practice has ever looked closely at your billing, watch our free briefing and see what your own aorta actually looks like. 

Resources (CTA priority order, MOFU) 

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. Guest resource: The Profitable Private Practice Playbook, EntreMD.com/privatepracticeplaybook 

Books referenced: Eat That Frog by Brian Tracy, The E-Myth Physician by Michael Gerber (both referenced by Dr. Una as early turning points). Series: not applicable, standalone episode.

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Two health plans sat fifty dollars apart in monthly premium. One covered forty percent of an inpatient stay, the other seventy five percent. Dr. Heather Signorelli walks through the exact process she used to shop for her own team's health insurance this year, and the mistakes worth skipping if you are doing this too. 

• Where we started looking: QuickBooks and brokers got us close to eighty plan options, but neither felt flexible or fast to compare on our own. 
• Finding a third way: a platform called Thatch, built around an ICHRA (individual coverage health reimbursement arrangement) model. 
• The trade-offs: how a fifty dollar premium gap can hide a thirty five point coinsurance swing, and why network type (HMO/EPO vs. PPO) matters as much as price. 
• Cost-sharing plans: why healthcare sharing ministries are not regulated insurance, and the questions to ask before joining one. 
• Catastrophic coverage and HSAs: pairing lower routine coverage with real protection against the worst case. 
• Business or personal: why the tax treatment question belongs to your CPA, not a guess. 

Three Actions This Week 

• Decide what you are actually protecting against before you compare a single plan. 
• Understand whether you are choosing a group plan or an allowance-based model like an ICHRA. 
• Get your CPA on the phone before deciding business vs. personal. 

Episode Breakdown 

Same chapter list as the YouTube description above (timestamps to be added after recording). 

Resources 

• Free second opinion / Metrics Audit VSL (primary): eligibility.natrevmd.com/metrics-audit-natrevmd 
• Practice Revenue Leak Scorecard (secondary): eligibility.natrevmd.com/nrm-revenue-scorecard-v3 

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We've spent a lot of time meeting with AI companies and testing technology in our own billing process. The lesson wasn't that AI can't help, it's that a tool solving one task can still make the whole revenue cycle harder without a designed handoff. 

• Lesson 1, fragmentation: Most AI vendors do one part of the job. The handoff to the next owner is what makes or breaks the value. 
• Lesson 2, implementation tax: A demo shows minutes of clean workflow. A live practice needs configuration, training, and an exception process. 
• Lesson 3, accuracy: Accuracy is a workflow result, measured with a baseline, not a demo result. 
• Lesson 4, staff concerns: Concerns about job security and quality are legitimate and need a named workflow owner, not a dismissal. 
• Lesson 5, ROI: ROI depends on size, volume, and starting problem. Smaller practices should start with one focused workflow. 

HIPAA note: do not put patient identifiers, clinical data, or payment information into a general-purpose AI tool without a signed Business Associate Agreement. 

Three actions this week: 

• Before adding any AI point solution, ask who owns the exception handoff 
• Set a measurable baseline before starting any AI pilot 
• Ask any AI vendor what percentage of transactions require human review in a live environment 

Episode breakdown 

• 00:00 Hook 
• 00:40 Why this matters right now 
• 02:30 Lesson 1: fragmentation 
• 06:00 Lesson 2: the implementation tax 
• 10:00 Lesson 3: accuracy as a workflow result 
• 13:00 Lesson 4: staff concerns 
• 16:00 Lesson 5: ROI by size and volume 
• 18:30 The four-question framework 
• 20:00 Close 

Resources 

• NatRevMD AI Kit: eligibility.natrevmd.com/natrevmd-ai-kit-tool 
• EMR/PM Evaluation Framework: eligibility.natrevmd.com/emp/pm-evaluation-framework 
• Metrics Audit Review (free, physician-led): eligibility.natrevmd.com/metrics-audit-natrevmd 
• Source: Healthcare IT News, August 24, 2026 survey 

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A 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