#186 The First Domino: Why Your Billing Problem Starts at the Front Desk

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

Transcript

SPEAKER_01 0:05

When we speak with practices, we hear their struggles. When a practice owner hires somebody, whether it's for the front desk, the back desk, an office manager, they're really thinking, how do I cover this position? Today's conversation is going to help us really understand how we not only fill the position, but how we craft a team that really gets us the results. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Sigmarelli, founder of Nat RevMD. Let's get started. Excited to have Josh on the show with us today. So, Josh, welcome to the show. Glad to have you.

SPEAKER_00 0:45

Thank you for having me, Heather. It's a pleasure to be here.

SPEAKER_01 0:48

Before we get started and talking about all the nitty-gritty about the staffing company, I'd love to hear your background because you come from a unique place with social working and behavioral health. And so just give me a background of you know where you started your career and how you ended up in a in a staffing company.

SPEAKER_00 1:03

Yeah. So uh went to school for social work and counseling. I got out of school, got into that field for a little while, got recruited by a staffing firm, and honestly didn't even really know what a staffing company was at that point, but got into that. It was kind of a startup and and it really took off. And and so I got into more of the HR side of things. And and then in 2008, it kind of felt like the staffing industry was the wild west. Here in Phoenix, there was a ton of recruiting firms, and um it really got to a point where it felt like it was more about who could get a resume to the client first versus focusing on you know a thorough screening process and and interview process. And and it it just didn't feel very good. And I felt like things needed to be different. I couldn't change what other people did, but I feel like I had a responsibility to the clients that I worked with. When when I was in school and social work, we learned that you know, social workers are are essentially vehicles of change. Um, we can't force people to change, but we can provide a pathway for change. And I took that approach into my next adventure. So I started my own recruiting firm in 2008 with a with a target of focusing on high-class service with an emphasis on relationship building. A lot of recruiting firms back then just they called it filled and build. They just filled positions and sent the clients the build. I wanted to be different than that. So I focused on long-lasting relationships and and uh 17 and a half years later, you know, here we are. I have clients that have are still with us from day one. Um we've been able to help practices stay open. We've been helping practices and get larger throughout the years. It's been really exciting and fun and really fun to grow and serve kind of as a a partner for those clients and bring the trust back into the hiring process.

SPEAKER_01 2:59

Yeah, and one of the things that I want to clarify is you you place like individuals typically in the practice, live in person for most of your roles versus like a virtual assistant or a virtual, these are US-based staff members that are going and typically working, maybe a hybrid of remote and in office, but most of them are in the office. Is that correct?

SPEAKER_00 3:20

That's correct. We we have a few different divisions, but our our longest lasting one and the and what we've built our foundation on at staffing first is working with private practices and in more of a direct hire role. So we'll recruit candidates, everything from medical records, front office, a billing to your you know, more clinical side of things, medical assistant, physician assistants, nurse practitioners, everything under the sun within private practice. Uh, we have a division for. And we started locally with working with practices just in Phoenix and have branched out to working throughout the U.S. And we also have a travel division that does travel nursing and allied health. And and then we do some work in the government sectors as well. But really, I think our bread and butter and the foundation of of what staffing first was built on was working with private practices. I love the the relationship that you can have. A lot of practices feel like a family, uh smaller than hospitals, and you really get to know a lot of the individuals there. It's a team uh environment, and it's really fun to be able to place key people in those roles within the private practice.

SPEAKER_01 4:25

And so do you help practices of any size? So, like a side, like maybe it's a single doc practice, they're looking for their first hire versus a 20 doc practice and they're looking for their you know 15th hire. It are you all over the map?

SPEAKER_00 4:39

I I love my larger practices. I love working with them and and helping them grow. Uh one one of my exciting parts of my job over the years has been working with one doc practices that are just getting going and helping them maybe make their first hire or or or find their office manager that's gonna help them take it to the next level. So yeah, all different sizes from one docs to to 25, 30 and and beyond. We love working with everybody in whatever situation they're in.

SPEAKER_01 5:06

And you know, I think one of the struggles, right? Regardless of if you're first starting out or you're been in practice and you've had, you know, you have 20 physicians or 20 providers who are on staff, is really creating that cohesive team. Because I don't think it's just about filling and finding this one spot. It's really about understanding what is this person going to do? What is their role in the company, and then what's the culture that is set. And so when you're starting with some of these consultations, I just imagine with your background, right? Behavioral health, social work, do you ever end up touching on kind of the psychology of the workplace and the culture and and how to get this new person on and hire and settled into the practice? Um, I just in speaking with you before, I just felt like that that was a niche and that I'd love for you to share just your process a little bit about your meeting with the practice maybe for the first time, getting to know their team and then helping find that right role.

SPEAKER_00 6:04

Yeah, that that that's a great point. I I probably take a lot of what I learned in the counseling realm and apply it to um not only my interactions with clients, but but also the recruiting process that we've established at staffing first. I think our clients say that I ask a lot of questions. I really have a lot of I try to ask a lot of clarifying questions in the beginning. And then when when they open up each order, I want to really understand every part of the practice that I can so that we can go and find the best individuals. Um also in the recruiting process. You know, we were taught to really focus on nonverbal communication, and candidates will give you a lot of that if you're looking for it. And I think that that may be a differentiator from maybe some other staffing firms or or help us stick out a little bit is we really utilize that behavioral health aspect, not only analyzing the skill sets that each candidate brings to the table, but also are they gonna be a good cultural fit for our clients? Every practice is different, right? And they're looking for different personalities. And you can be an experienced biller with great tenure and and all that, but if you don't have the right personality and a practice, is it gonna work? And so we really dive deep into that aspect too, and not just focus on the skill set, can this person do the job? But are they gonna be a good fit for the practice?

SPEAKER_01 7:21

Yeah, well, I think one of the things we're seeing with practices is struggling with front desk individuals, that front office, the patient, it's gotta be f you know, they're patient-facing. So it's a different skill set than someone in the back office, as you know. Just from a personality and also just a desire to be sort of front and center because they're gonna be the first person the patient sees. Um, are you guys seeing any trend when it comes to filling these roles just from a front office perspective? Are you seeing that these roles turn over more frequently than other roles? Um, I'm just curious what your practices are seeing.

SPEAKER_00 7:55

I think that's always been a challenge with practices. Um, it probably is a little bit more now than it has been in the past with turnover. Practices are hiring less, you know, all across healthcare. If you need three or four front office, maybe a practice is hiring one or two. Um, there's that compensation gap where candidates are looking a lot, looking for a lot more hourly wages than what practices can afford. So there's that aspect of it. And I think there's just there's been a breakdown uh between trust between candidates and employers within healthcare where there's not that consistency that there used to be. You can still find people like that, but in the front office, it's a tough position. We don't look at it like that, but they're answering phones all day dealing with patients and and a lot of different interactions like that. So it's a tough role. And if there's if there's not good processes in place, uh it's it's very easy for there to be high turnover within practice.

SPEAKER_01 8:51

Yeah, and you know, I think it is uh that's uh very much what you mentioned about the gate the wage gap. I do see that as like a really uh an issue that we're seeing in practices is as that wage that folks are expecting has gone up, some practices may not always be able to stick with it. And so I think finding that right person from the beginning is really, really critical. We have some of our offices who have the same front office staff who've had them for years and years, and others who tend to turn over. Um, and that can be for different reasons. One of the things that we try and help practices with is really getting when you do bring that person on and really getting a true understanding of role, role and responsibility and onboarding, because I think if you can have a really good onboarding experience and the individual really knows what their expected day-to-day tasks are, typically, you know, even in my role with our own company, also on the hospital side, like people get tend to get stickier, right? And so that first year, if you can avoid first year turnover, which typically has to do with onboarding and culture fit, setting expectations and all of that being really, really clear up front, we see practices having a much more successful hire and that person staying longer. At least that's been my experience. But, you know, correct me if if that's if you have a different experience.

SPEAKER_00 10:09

Absolutely. I mean, I think there's a lot that goes into uh the process before that person even starts in their position. And and you spoke on it. Uh, me personally, when I'm hiring somebody from my office, my goal is for them when they start on the first day to not have any surprises, to not say, oh, Josh didn't tell me about this or that. I try to be as thorough as possible of what the expectations are, what the environment is like in our office. And and I passed that along to some of our clients as well. I I think you can put yourself in a position where you can have the most success. It doesn't mean it's going to be successful every time, but if you're doing the right onboarding and really having a major understanding of what that practice needs, we'll have clients that'll call us and say, hey, we need a front desk person to do scheduling and check-in patients and answer phones. But really, they need somebody that has a thorough uh knowledge of in insurance uh verification and uh to be able to ensure that there are no issues before a claim goes out. But if you don't understand what your practices needs are and you're just going out and hiring and shooting from the hip, more than likely, you know, that's a that's a good recipe for a high turnover.

SPEAKER_01 11:19

Yeah, 100%. And I I think folks getting there going, oh, I don't know uh how to do any of those things, and then they feel frustrated, and I could see how they would say, especially in an environment where, you know, maybe it's easy to go get another job, they're like, well, you know, I I didn't know that ahead of time. I feel I feel uncomfortable or I feel um, you know, awkward in doing those those types of uh positions or roles. So hear you 100%. When you see offices that maybe are struggling with that front office person, you know, what is your understanding of how that impacts the downstream revenue? You know, if we've got practices that maybe have a gap today, but they're like, oh, well, I I don't, you know, know, I don't have time to hire, I don't have time to interview. What are you seeing for those practices on the back end in terms of revenue?

SPEAKER_00 12:05

Well, you know, the front desk is the first domino in the billing cycle, right? And if you're not getting the correct information at that point, or if that person hasn't been trained or isn't the right fit, you may see billing issues 30, 60, 90 days down the line. And a lot of practices just think of it as problems with their billing department versus, you know, what's what's going on with the most recent hire in the front office. It's hard for practice managers these days to take the time to analyze every part of this because they have so much on their plate. It's important and it's something that should be done, but are they able to do that with all the responsibilities that they have and the oversight? And so, you know, we're seeing that companies that have billing issues not necessarily have it within their billing departments. Um could be, you know, a lot of it on the front end of turnover within the front office where there's a lot of things that fall through the cracks, or people that weren't trained correctly or bring bad practices from from other employers or just aren't the right fit and aren't doing their job. And, you know, when you don't have the right information in the beginning, it's really hard to get paid for those claims.

SPEAKER_01 13:14

Yeah, a hundred percent. I mean, and I uh we do see the number one denial in our practices is eligibility. And we also see it's really interesting, we also see people practices with high turnover of billing companies. And one of the reasons that we see this is because of that coordination between the front office and the back office. And so even if that billing team is outsourced, but they don't have the right staff in the front, but then the billing team that's outsourced isn't coordinating the eligibility concerns or the denial concerns to the front desk. The practice manager may have no idea that they have an eligibility issue. And so we truly see for us the front desk staff member as being the number one role that you got to get right. But then it's also a coordination effort between the billing partner or the billing team if they're in-house, the office manager and the front desk and getting all of those individuals, you know, whether it's on a huddle or something on a weekly basis to go over those issues. And so again, I think to your point, having that key front office staff is critical. And so if for you guys that are listening, if you guys are struggling with these types of roles or you you know you have some gaps, Josh's team can help and really understand what it is you need and help get all of those uh checkpoints in in order so that you hire the right person from the beginning. And, you know, how do you guys help with onboarding or what's your process where you've identified a candidate, the the practice has maybe interviewed a couple. How many times or how many uh candidates do you typically bring to a practice?

SPEAKER_00 14:43

Yeah, I mean, if we're if we're let's just keep with the the front office example, you know, if we get an order for a front office, you know, we'll maybe interview on average 10 to 12 candidates and and send our top two or three. That's another part of it too. We want to save our practice managers a lot of time. They, again, they have a lot on their plate, and some of them are forced to do some of their own hiring. And uh they think, how am I going to fit that in with everything else? You know, and so if the docs can give the go-ahead to to use a staffing firm, you know, that's one of the benefits that we can bring is saving you a lot of time, really pushing forward the top candidates out there that we feel seem to fit your practice. We don't look at, you know, front office or medical assistants or billers as any less important than a physician assistant or nurse practitioner. They they all play their role. And, you know, if if you have a breakdown in the front office, that can seriously cause problems with getting paid on claims. It can cause issues with, you know, patients coming in that didn't get a good experience from your practice. There's so many things that can happen who take them seriously.

SPEAKER_01 15:52

Yeah. And then they and if they leave a bad review, then that's another can be another issue that downstream that can't another knock totally. So it you know, if somebody listening wanted to come and just understand how you would work with their practice, what's the best way for them to reach you?

SPEAKER_00 16:08

Yeah. They can send me an email at JSON at staffingfirst.net. They can look me up on LinkedIn. Um, you can also shoot me a message uh through our website, www.staffingfirst.net. You know, I I love having conversations with people. I I love just talking through things with people. And there's a lot of times where we can help some practices out without even, you know, recruiting for them. Sometimes there's just a a process issue that you've got to alter a little bit. I'd be happy to have a conversation with anybody out there. And if you do need some staffing services, we can look and see if we can help you and all that. But love having conversations with people just like this and talking through problems.

SPEAKER_01 16:50

And remind me again, do you uh recruit for any clinical roles? Like if you do physicians and mid-levels as well, right? I just want to make sure the audience knows that.

SPEAKER_00 16:59

Yeah, we don't do physicians, that's the only thing, but we do nurse practitioners, physician assistants, uh, all clinical roles, nurses, uh, and then of course all behavioral health roles and licensed social workers and therapists and case managers and and all of that. So yeah.

SPEAKER_01 17:16

Okay. Wide, wide net there. That's great. Okay, great. Well, anything else for the listeners today uh that you want to share uh before we go?

SPEAKER_00 17:24

Yeah, I'd probably leave you with that, you know, staffing is important and it's important to really know your process well because if you don't, you're not gonna really know exactly who you need to hire. Hiring and staffing is is part of your infrastructure, so you need to approach it that way. And it really starts at the top. So you need somebody who's knowledgeable in management that understands the process and everything that you're doing within the practice well, and then they can go out and hire accordingly. Um, and also, you know, I think now is a better time than ever to outsource some of that stuff too. Um, I used to not be a huge fan of that, and and now I am with the turnover that some of the practices experience and all of that. And if you do choose to do that, you still need somebody knowledgeable in the practice that that can serve as somewhat of a liaison between the practice and the billing company because it is a partnership. The billing company does need valuable and and accurate information, and you need somebody that's working between both the practice and the billing company to ensure accuracy and consistency and accountability. So yeah, I would say that uh, you know, we're here to help in any way that we can, but knowing your process is key and knowing who you need to hire.

SPEAKER_01 18:35

And now with AI, I think it's a really great time for you to be able to sit down and go, okay, what do I want these people really to do? And then I think leveraging a partner like yourself to then have those ideas and bounce back and forth because you've seen it all, right? You've you've helped hundreds of practices, you've seen practices that are one doc to you know, multi-site locations, you know, to to even larger practices than that. And so I think the feeling of like I have to do it all on my own, or I have to stay in my little bubble and just try and figure it out, I think is outdated. I think now that we have technology tools, partner tools, it's really pulling all of that together to really create what the future could look like.

SPEAKER_00 19:16

Yeah, yeah. And one last thing too, I you know, we see it through private practices, smaller offices, big hospitals nowadays, too. You know, we're seeing that, you know, everybody is trying to save money on staffing services and that's fine, or or even trying to save money on not hiring the way they normally do. But we have found in the 17 plus years that we've been working that trying to save money and and skimp a little bit here or there, or hire less experienced people end up costing you a lot more in the long run and end up being, you know, a bigger expense uh for the practice or the hospital. And so and that's what we're seeing a lot these days as well.

SPEAKER_01 19:50

Yeah. Again, uh, what's the saying? Hire slow, fire fast. So I think get it right the first time, and then if you know it's not right, like let's get that person moving on. So uh thank you so much for being on the show today. I really appreciate it. It's good to have you somebody with your years of experience on and sharing your experience and how you help support practices. So thank you so much. I look forward to um sharing this with our audience. And again, we'll put all of those contact notes in the show notes so you guys uh can get in touch with Josh or his team as you guys need. All right. Thanks so much for being on.

SPEAKER_00 20:23

Thank you, Heather. I appreciate it.