Work record / Operating / PE-backed medical group

One map first: auditing a PE-backed medical group

A private-equity-backed medical group with dozens of offices had a pile of vendors and no map of them. I took the fractional COO seat to audit operations and efficiency, and I decided that nothing gets built until the whole operation is on one page.

The seat

I hold the fractional COO seat through Common Ground. The group came to us in July 2026 through a capital partner, and the job is a ninety-day operations and efficiency audit that covers IT, HR, FP&A, marketing and revenue cycle. We also write the roadmap that follows.

What I was brought in to decide

The client is a private-equity-backed medical group with dozens of offices, put together by acquisition. Every office came with its own tools, website, vendor contracts and doctor-partner, and no one owned the whole picture. Leadership said vendor sprawl in IT, inside a HIPAA-regulated environment, was the biggest pain. They also wanted people moved into better work and not cut. An earlier conversion to a single platform had run $50,000 to $100,000 for each office, and the ongoing IT bill had not come down.

The group stays unnamed. It reached Common Ground in July 2026 through a capital partner. We hold the fractional COO seat on the audit and write the roadmap that comes after it.

What we did

• No contract existed yet when I built an acquisition vetting engine. It is a hosted scoring rubric with five weighted criteria, producing a composite score out of 100. It uses operational and financial inputs at the practice level and never touches patient records. I did not pitch a buyer of practices. I scored five practices on the market that week. Scores ran from 85 down to 45. Then I invited the client to argue with what the engine produced.
• We scoped the audit as map first, govern second, build third. It covers audit, analysis and recommendation only. If a build follows, it gets a separate statement of work after the question ahead of it is answered.
• The first open question is how the practice-management platform is laid out: one database, or one for each office. Depending on the answer, any data work takes either about two weeks or about three months.
• Vendor governance comes ahead of vendor replacement. I set up a register holding a business associate agreement, service levels, renewal dates and a single owner for every vendor that touches protected health information. We framed the IT work as vendor rationalization, not a review of one department. The register records each stated rate as a rate and never multiplies it out. Websites cost $725 and about $750 per office per month. A data connector is $50 and practice analytics $300 to $500. Per-location connectors and VPN come to $400 to $600.
• Patient communications run only on infrastructure under a business associate agreement. We ruled out GoHighLevel, a general marketing-automation platform, for protected health information. We build the layer on Twilio under a BAA, plus HIPAA-capable email, plus n8n that we host ourselves on infrastructure a BAA covers, plus a language model that is also under a BAA.
• For clinical AI we buy and integrate, and do not build. Overjet, Pearl and Videa are the names in that class. The build budget goes to the integration layer the group will own.
• Money flows with weak controls come first. About 75 percent of payroll is computed centrally and 25 percent in the offices. Spot checks are the only review of doctor-partner pay. Reimbursement from insurers lands in 30 to 60 days. We start with three things: one payroll view, a control over how compensation is calculated, and an accrual policy.
• Quick wins show up around day 25 of each thirty-day cycle. Examples are duplicate tools, security settings nobody switched on and vendors paid twice. So each report leads with something already finished.

Results

• Within 18 days the introduction turned into an audit contract ready to sign. Outside counsel took the retainer from a second draft to a thirteenth. On August 14, 2026 the client walked through the portal, then the live scoring engine, then the near-final contract, and treated the three as one decision.
• We are under retainer, and the ninety-day audit is under way.
• What exists so far: a map of current-state systems, a register of vendor rates, the revenue-cycle analytic for the second cycle, a scorecard template for vetting, and the cycle plan.

The lesson

Map the whole operation before governing any part of it, and govern before you build anything.

Stories from this work

Questions about PE-backed medical group, answered

Firm record

Common Ground keeps its own account of this engagement: PE-backed medical group on the Common Ground wiki.

Back to all projects