A quality of earnings report tells a sponsor what a practice earned last year. It says very little about why. Two practices with the same EBITDA can look identical on paper while one answers every call and fills every slot, and the other loses a third of its new-patient inquiries to voicemail. For a roll-up, that difference is the value creation plan. It is worth knowing before the LOI, not after close.
Why the Front Office Belongs in Diligence
- It is where the upside is. Missed calls, no-shows and overdue recall are revenue the practice already generates demand for but does not capture.
- It is where the risk is. A practice that depends on one long-tenured front-desk manager can lose performance quickly if that person leaves.
- It sets the integration plan. Knowing the target's PMS, phone system and workflows up front tells you how long onboarding will take.
- It sharpens the price. Gaps you can fix are upside for you. Gaps you cannot fix are a reason to adjust the offer.
The Front-Office Diligence Checklist
1. Access and Demand
- Inbound call volume by hour and day of week
- Answer rate, abandoned calls and calls reaching voicemail
- After-hours and weekend inquiry handling
- Web form and text response time
2. Schedule Performance
- Schedule fill rate by provider
- No-show and same-day cancellation rates
- How cancellations are backfilled, if at all
- Days to next available new-patient appointment
3. Patient Retention
- Share of active patients overdue for recall
- Unscheduled treatment or follow-up visits
- Patient reactivation process and frequency
4. Reputation
- Google review count, rating and recent trend
- Whether review requests are sent, and how
5. Systems and Staffing
- EHR, PMS and phone system in use
- Front-desk headcount, tenure and turnover
- How much of the workflow lives in one person's head
How to Get the Data in a Short Diligence Window
Most of this data exists, but not in a report anyone at the practice has run. Phone system call logs, PMS appointment history and a review profile cover most of the checklist. A few practical steps:
- Ask for raw exports, not summaries. 12 months of appointment and call logs tell you more than any self-reported number.
- Run a mystery-shopper test. Call at lunch, after 5pm and on a Saturday, and see what happens.
- Compare against your platform. If you already run several locations on one operating system, your own locations are the best benchmark.
Platforms running Rollup Engine (AIP) already have standardized KPIs across their existing locations, which makes a target's numbers easy to put in context.
Turning Findings Into a Day-One Plan
The output of front-office diligence should not be a list of problems. It should be a sized plan:
- Size each gap. For example, if a practice misses 25% of 400 monthly new-patient calls and converts answered calls at 50%, capturing those calls is worth about 50 new patients a month. Multiply by average first-year patient value.
- Assign each gap to a workflow. Missed calls to 24/7 answering, no-shows to confirmations, open slots to waitlist fill, overdue recall to recall campaigns.
- Set the go-live date. With Samara, a new add-on can be live on Operations Engine (AIT) in under 30 days, so the plan can start in the first month after close.
- Baseline it. The diligence numbers become the baseline, so post-close improvement is measured against what you actually bought.
For what happens next, see the first 100 days of M&A integration and going live in under 30 days.
Next Step
See how Samara supports private equity deal teams, or book a demo to review a target practice's front office with us.
Frequently Asked Questions
What is operational due diligence for a healthcare practice?
It is a review of how a practice actually runs: call handling, schedule performance, recall, reviews, systems and staffing. It complements financial diligence by showing where revenue is being lost and how much could be recovered after close.
What front-office metrics matter most in a roll-up acquisition?
Call answer rate, new-patient conversion, schedule fill rate, no-show rate, overdue recall and review volume. Together they show how much demand a practice captures and how much it leaves behind.
How quickly can improvements start after close?
With Samara, a newly acquired location can be live and ROI-enabled in under 30 days, connected to its existing EHR and PMS.