Most practice owners check one financial number: the bank balance. Preston Alexander, writer of The Healthcare Breakdown, calls it management by bank account. In this conversation with Dr. Heather Signorelli, he explains why it keeps good practices one slow month away from the line of credit. Cash timing is the hidden problem. A practice that opens on February 2 should not expect meaningful insurance payments until April or May. Credentialing and billing setup take time, even for experienced teams. Practices that never planned for those months often spend years operating from behind. Revenue and expenses are one conversation. Billing metrics and the expense side usually live in separate places. Preston's team looks at CPT-level profitability, overhead allocation, and expense timing month by month so owners see the whole picture. Stable is not the same as healthy. Heather describes practices where billing is finally dialed in and payroll is still tight, usually because compensation was set before the revenue was forecast. Options include a smaller base with a bonus on what is left. The second location trap. A new address creates billing issues even under the same TIN, so Preston plans for about six months of near-zero revenue. Market fit matters just as much: referral patterns, the dominant health system, and payer mix. Heather adds that a drop from $175 to $140 revenue per visit changes what volume you need and what you can afford to spend. Three actions this week: • Pull your last 12 months of financials and ask why each line that grew went up • Ask one vendor you have paid on time for years for longer payment terms • Block one hour a week to review revenue and expenses side by side