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A 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. 

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Q1 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 

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Deliver 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 know

Deleted 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 rounds

Workflow fix                                                    Timestamps · billing hard stop · daily                                                                                    reconciliation

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 3 (EP191): https://podcasts.apple.com/us/podcast/191-labor-management-is-no-longer-invisible/id1624182351?i=1000775009191

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Under 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

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Starting 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 know

• Deleted codes count                     -      17 codes deleted total 
• Antepartum-only codes                  -       59425, 59426 — deleted Jan 1, 2027
• Global 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 rates
• Modifier 25               -       On the E/M when a procedure is also billed same day
• ACOG test date         -September 1, 2026 — recommended start for test claims
• RVU 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=1000773393336
• Coming next: EP191 · Phase 2 labor management codes (the codes that have never existed in CPT before) 

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Show 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.

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Show 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 

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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) 

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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  |  [email protected] 

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

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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