When the practice is losing money, the first job is to see the cash.
A practice that cannot comfortably make payroll, a surgery center losing money on every light week, a vendor threatening to go COD: these are cash problems before they are anything else. The work here is stabilization. One forward view of cash for the next 13 weeks, a deliberate order for who gets paid, and preparation for the creditor and vendor conversations that cannot be postponed. Then the fixes that stop it from happening again.
By the time it feels urgent, it has usually been building for a year.
Payroll is getting tight
Collections are lumpy, the bank balance swings, and every other Friday has started to feel like a coin flip.
A creditor is calling
A lender, a landlord, or an equipment lessor wants an answer, and there is no plan yet to anchor the answer to.
Vendors are squeezing
Terms are shortening, a supplier is threatening cash-on-delivery, and the contracts draining the most cash have never been renegotiated.
The center loses money quietly
A surgery center or satellite location that underperforms every month, carried by the rest of the practice, with no number on what it actually costs to keep.
Stabilize first. Fix second. Keep the discipline third.
A rolling 13-week cash plan
Built from actual receipts, payer remittances, payroll, rent, debt, and vendor obligations, updated weekly. The bank balance tells you where you are; this tells you what is about to hit.
Payment sequencing
One deliberate order for who gets paid and who waits, decided on consequence rather than on who calls loudest. Payroll and the obligations that can shut you down come first.
Creditor conversation prep
For each creditor: what to ask for, what you can actually commit to, and the sequence, so the conversation that frees the most cash happens first. You hold the conversations with a plan behind them.
Vendor and contract renegotiation
The handful of contracts draining the most cash, priced bottoms-up against what the service actually costs to provide, with the analysis your counsel needs to reopen them.
The root-cause read
Why the practice got here: collections, payer mix, a location or service line that loses money, a facility arrangement priced years ago. The crunch is a symptom; this names the cause.
The standing seat, once stable
The cash plan becomes the operating cadence of a fractional CFO engagement, so the discipline that got you through the crunch is the reason there is not another one.
Days matter here, so the engagement is built for speed.
Week one: the cash picture
Bank activity, receivables, payroll, and obligations pulled into the first cut of the 13-week plan. You see the real runway, usually for the first time.
Weeks two and three: the conversations
Payment sequencing agreed, creditor asks prepared in priority order, and the first renegotiations opened with numbers behind them.
Then: the fixes
The root causes worked one at a time, with the weekly cash plan as the scoreboard for whether each fix is actually landing.
The engagement is a flat, fixed advisory fee, scoped in writing and paid in advance of the work. Every analysis is framed as the numbers and your decision, prepared for internal planning.
Scope boundary. This is financial analysis and preparation, not legal representation. Where a matter involves loan default, workout agreements, or potential insolvency, your restructuring counsel leads and this work feeds them the numbers. Part of the job is telling you plainly when that point has been reached.
A read built on the buy side, pointed at your side of the table.
Healthcare M&AI is led by Shawn Rothlis, a practitioner with 8+ years in corporate development, M&A, and strategic finance across 130+ healthcare centers acquired and integrated. Buying and integrating struggling centers means seeing, over and over, exactly which numbers a practice in trouble stops watching, and which levers actually move when cash is short.
Recent stabilization work includes a rolling 13-week cash plan and preparation for four creditor conversations for a single-physician surgical practice, and a facility arrangement rebuilt bottoms-up that surfaced roughly $464,000 a year being left on the table. Client names withheld; outputs paraphrased to preserve confidentiality.
Questions owners ask when cash is tight.
What do I do if my practice cannot make payroll?
First, get one forward view of cash: everything coming in, everything due, week by week, for the next 13 weeks. Most owners in a crunch are managing from the bank balance, which shows where you are but not what is about to hit. With that view, payroll, rent, debt service, and vendor payments can be sequenced deliberately instead of by whoever calls loudest.
What is a 13-week cash flow plan?
A weekly forecast of cash in and cash out for the next quarter, built from your actual receipts, payer remittances, payroll, rent, debt, and vendor obligations rather than from the P&L. It is the standard first deliverable in stabilization work because 13 weeks is long enough to see the crunch coming and short enough to be accurate.
Should I talk to my creditors before or after I have a plan?
After, and usually within days rather than weeks. A creditor conversation without a cash plan behind it is a plea; the same conversation with a specific, defensible number and date attached is a proposal. The preparation covers what to ask each creditor for, in what order, and what you can actually commit to.
Do you negotiate with creditors for me?
The work is preparation and analysis: the cash plan, the sequencing, the number you can commit to, and the script for each conversation. You or your counsel hold the conversations. Where a matter involves loan default, workout agreements, or potential insolvency, a restructuring attorney belongs in the room, and part of the work is knowing when that point has been reached.
What happens after the practice is stable?
The same forward view of cash that got you through the crunch becomes the operating discipline that prevents the next one. Most owners keep the seat as a standing fractional CFO engagement: monthly performance reviews, the cash plan maintained, and the decisions that caused the squeeze fixed at the root.
The crunch is survivable. Managing it blind is what does the damage.
Send the bank activity and the obligations. Within days you have one view of cash, a payment order, and a plan for the conversation that matters most.