How to navigate the “messy middle” of practice growth

You hired another therapist. Then two more. The waitlist stretched, and your days turned into a web of shifting appointments, room assignments, and paperwork. Growth is happening — and it should feel good — but it often feels like the messy middle: when demand outruns the systems meant to support it.

Most practice owners reach this point. Whether you’re expanding within a single location or adding a second site, the friction is the same: the administrative load rises faster than revenue, workflows splinter, and decisions turn reactive instead of strategic.

This phase is normal — and most importantly, fixable.

Quick self-assessment: Are you in the messy middle?

Growth can creep up on you, with its challenges often disguised as minor daily frustrations. Answering “yes” to a few of these may mean it’s time to shift from managing day-to-day tasks to building long-term systems:

• You need multiple calendars or workarounds just to manage one schedule.
• Administrative hours are increasing without faster reimbursements.
• Your no-show rate climbed above 10% (the industry benchmark) last quarter.
• You or a clinical director are covering the front desk because “it’s faster if I do it myself.”
• New hires take weeks to ramp up because training varies based on who they shadow.
• Cash flow feels tight every payroll cycle, even when your schedule is full.

Score yourself:

• Answered “yes” to 2–3: You’re approaching the messy middle — now is the perfect time to build stability.
• Answered “yes” to 4–6: You’re firmly in it. The strategies below will help you regain control.

Reducing no-shows

Missed visits cost U.S. practices about $200 per slot and often add up to $50,000–$150,000 in annual losses, making no-show reduction one of the quickest financial wins for unsteady times.  

Research shows that no-show rates rise sharply when appointments are booked more than two weeks out. One study found rates climbing from 9% when booked 0–2 weeks out to 38% when booked six months ahead. To shorten booking times, many practices keep an actively managed waitlist, use virtual visits to open up sooner appointments, and offer at least one “rapid-access” slot per therapist each week (to handle lastminute/emergency appointments without blowing up the schedule).

Intake friction adds to the drop-off. Clients with active portal accounts – including online paperwork and scheduling options – were 21.5% less likely to noshow, based on 1.6 billion outpatient visits.

Reducing those two barriers — long waits and clunky intake — keeps schedules fuller and revenue steadier. You can learn more about decreasing no-shows here.

Tightening eligibility & benefits verification

Missing or incorrect insurance information hurts more during growth because each denied claim feels multiplied by your larger payroll and cashflow needs.

• Nearly 26.6% of all denials come from eligibility mistakes — meaning a big chunk of your money problems are totally preventable.
• Top performers keep eligibility-related denials below 3% by double-checking benefits early and often.
• Automated verification can shrink verification time to under 60 seconds — which means less waiting, fewer bottlenecks, and a happier team.
• Accurate verification = faster payments + fewer surprises for patients, which boosts trust and keeps your front desk feeling like heroes instead of firefighters.

Simple steps like 1) verifying insurance more frequently and 2) updating your systems to automate client verifications can make this phase feel less hectic.

Making your processes repeatable

Instead of reinventing the wheel each week, design repeatable processes that set one reliable rhythm. This protects cash flow, lightens cognitive load, and makes onboarding feel simple and supportive.

Simply put, repeatability brings:

• Consistency → creating predictable cash flow and cleaner claims by reducing avoidable errors at the front and back end.
• Clarity → enabling faster, better decisions because everyone follows the same playbook across sites and roles.
• Confidence → letting teams work proactively instead of reactively – less firefighting, more forward motion.

Top 6 SOPs to standardize first:

1. Intake workflow
Tip: Use smart intake forms that expand based on responses (e.g., work-comp, secondary insurance) so you collect all payer critical details before the visit.

2. Eligibility & benefits verification
Tip: Run event-based rechecks (reschedules, provider changes, plan renewals), so eligibility doesn’t quietly expire mid-episode.

3. Documentation expectations
Tip: Use note templates that show payer rules right inside the chart so therapists document correctly the first time.

4. Plan-of-care tracking / treatment updates
Tip: Show visit counts and expiration dates right on the schedule so no one accidentally treats under an expired plan.

5. Denials workflow
Tip: Sort denials by what actually caused them so you can fix the root issue, not just that one claim.

6. Payment posting
Tip: Tag payer adjustments as they come in so you can spot underpayments or trends before they become real problems.

Protecting therapist time

Your therapists feel the messy middle more intensely than anyone. They’re delivering care, handling documentation, managing authorizations, and absorbing every operational inefficiency that slips through the cracks.

Protecting their time is both a retention strategy and a growth strategy.

Reducing administrative burden

Administrative overload — not client care — is often a primary driver of therapist burnout across disciplines. For example, in our Future of Therapy research report, 82% of mental health therapists reported burnout, with 53% reporting insurance frustrations as a major contributor. And 90.8% of physical therapists cited administrative burden as a key contributor to burnout in APTA’s 2025 survey – with 85% saying that prior authorization processes negatively affect client outcomes.

You may not be able to fix the entire insurance industry, but you can fix internal friction. This can involve anything from creating documentation templates to streamlining how prior authorizations are handled.

Speeding up documentation

If therapists are documenting at lunch or after hours, your workflow is signaling distress.

Tools like quick‑phrases, standardized templates, and ambient notetaking technology (like AI Session Assistant) can help reduce documentation time dramatically

The objective is to protect four to six hours of therapist focus time each week. Think about what your team could do with an extra hour every day. They could see another client, collaborate with colleagues, or simply leave work on time.

Additional resources

No-show reduction checklist

• Enable online self-scheduling.
• Activate client portal accounts for all active clients.
• Shorten appointment lead times by offering same-day or next-day slots.
• Use a consistent reminder cadence via text/email.
• Set a clear late-cancellation policy and communicate it during intake.
• Watch how your no-show rate changes based on how far out clients book – it’s an easy way to spot patterns you can fix.

Policy watch

• CMS Telehealth & Remote Monitoring (2026): CMS introduced updates that apply across outpatient specialties, expanding how therapists can deliver and bill telehealth and remote monitoring. Changes include added telehealth service codes, clarified audio-only requirements, and more flexible virtual-supervision rules, helping both rehab and mental health practices maintain compliant, hybrid-friendly care models.

To try this week

Growth doesn’t have to be chaotic. Pick one friction point, refine it, standardize it, and build from there. Each small win creates more clarity, more consistency, and more breathing room for your team and your clients.

You’re building something meaningful. And while the middle may feel messy, you’re moving forward — one intentional step at a time.