When each seat fits.
| Seat | Typical practice size | What it solves |
|---|---|---|
| Bookkeeper | Under $2M | Transactions, basic reports, payroll, A/P. |
| Controller | $2M–$7M | Accurate close, controls, monthly reporting, budget variance, lender-grade statements. |
| Fractional CFO | $3M–$25M | Forecasting, payer strategy, profitability analysis, capital decisions — without the full-time cost. |
| Full-time CFO | $15M+ | Daily strategic decisions, transactions, board reporting, capital structure. |
Warning signs you’ve outgrown the seat.
- Financials arrive late, get restated, or you don’t fully trust them.
- You can’t answer “where will cash be in 90 days?”
- You can’t name which providers or services actually make money.
- Every financial decision routes through the owner.
- A capital event (sale, partner buy-in, lender) exposes diligence gaps.
The three levels of finance support.
Every practice has a finance function whether they realize it or not. The question is whether it’s adequate for the size and complexity of the business. There are three levels:
- Bookkeeper — transactional. Records what happened. Required for everyone.
- Controller — structural. Builds the chart of accounts, runs close, produces reliable monthly statements, manages cash, tax coordination. Most practices over $3M revenue need this.
- CFO — strategic. Forecasts, scenarios, capital planning, payer negotiation support, M&A readiness, board-level reporting. Practices over $8–10M benefit; multi-site groups effectively require it.
The mistake most owners make is hiring at one level and expecting work from the level above.
Build, buy, or borrow.
Three structural options:
- In-house — full-time hire. Best when the practice has enough work to fill the role and the complexity warrants it.
- Fractional — outsourced controller or CFO on a defined cadence. Good fit for practices in the $3–15M revenue range who don’t justify a full-time hire.
- Hybrid — in-house bookkeeper plus a fractional controller or CFO above. Common and underrated.
The right answer depends on revenue, complexity (single location vs multi-site), and where the owner is in the journey (growing, optimizing, preparing for sale).
What good finance work produces.
You know your finance function is working when:
- Monthly financials close by the 10th of the following month, reliably.
- The chart of accounts mirrors how you actually run the practice (by service line, location, provider).
- Owners get a 1-page summary they actually read — not a 12-tab spreadsheet.
- Tax planning happens quarterly, not in March.
- Cash decisions are made against a forecast, not against the bank balance.
Questions practice owners ask.
When do we need a CFO? When the decisions you’re making are too large to make without modeling, or when you’re preparing for sale, recap, or a major capital event.
Can our accountant do this? Usually not. Tax accountants do tax. The work above is operational finance, which is a different discipline. A good tax accountant is essential; they’re rarely the right person to run the practice’s finance function.
How much should we spend on finance? Most well-run practices spend 1.5–3% of revenue on the finance function (bookkeeping, controller, CFO, software, tax). Under-investing here costs more than it saves.
Finance Function Assessment.
A 15-minute review that matches your current finance seat to the size and complexity of the practice.
Request the assessment