What Your Bookkeeper Should Actually Be Doing for Your Therapy or ABA Practice

Earlier this year, the owner of a group practice with about a dozen clinicians told me her accounting firm had raised its rates. When she asked why, the firm explained that they had “been providing CFO services” all along. She had never met with anyone at the firm. There were no forecasts and no dashboards, and the work the firm did do was solid: the books were reconciled and the returns were filed on time, which is what made the increase hard to evaluate. She was paying for bookkeeping, being billed for something called CFO services, and had no reference for what the difference should look like.

She is the common case, not the exception. Most practice owners I talk to already pay someone for their books, and the books are usually done: transactions categorized, accounts reconciled, a P&L available on request. The owner still cannot answer whether they can afford their next hire, which service lines make money, or why profit on paper never shows up in the bank account. The problem is rarely the person. Nobody ever showed the owner what each level of financial help is supposed to produce.

This article is that reference. It lays out the four tiers of financial help and the tax work that runs beside them, what each tier should hand you every month, what each costs at market rates, and how to figure out which tier you actually have, as opposed to the one named in the engagement letter. If a tier turns out to be missing, it also covers how to vet the person you add.

Bookkeeping, accounting, and finance are different jobs

Your practice needs two functions covered, and they are frequently sold in one bundle, which is where most of the confusion starts.

The first is the finance function: recording what happened, closing the books each month so the numbers stop moving, and interpreting what they mean for decisions. This function stacks in tiers. Each tier does everything below it, plus a layer the lower tiers are not built for.

The second is the tax function: returns, quarterly estimates, entity elections, compliance. This is your CPA’s home territory, and it runs beside the tiers rather than on top of them. A solo practice has a CPA. An $8M group has a CPA. It is not a stage you graduate through.

Few of the owners I talk to have ever seen a job description for any of this. They hired a person, or a firm, and inherited whatever that person happens to do. So the most common failure I see is not a bad vendor. It is an owner asking the tax function to do the finance job. When a CPA says he legally cannot advise you on what to pay yourself, or your accountant goes dark from May to February, that is not negligence. That is a tax professional being asked a finance question. The reverse failure also happens: a practice pays a CPA firm a bundled monthly fee that includes “bookkeeping and advisory,” and the finance layers above basic bookkeeping go unstaffed while everyone assumes someone else is covering them.

Practice owners keep a running list, whether they know it or not, of questions their current help could not answer. The list is consistent across practices:

• Can I afford to add a clinician, and when does that hire break even?
• What do I actually earn per service line, per payer, per location?
• What should I pay myself?
• Why does my P&L show profit while my bank account stays flat?
• What does next quarter look like if I sign this lease?

None of those questions belong to a bookkeeper. None of them belong to a tax-season CPA either. They all live in the upper tiers, and if nobody in your current setup owns those tiers, the questions go unanswered no matter how good the people are.

The four tiers, from DIY bookkeeping to a fractional CFO

Tier 1: Doing your own bookkeeping

You, QuickBooks or a spreadsheet, and whatever evenings you can spare. Published guidance suggests formalizing bookkeeping by roughly $100K to $150K in annual revenue. Below that, DIY is a defensible choice. Above it, the cost is not the errors you make. It is the hours you spend making them, and the decisions you defer because the numbers feel unreliable.

What this tier should produce monthly: there is no answer, and that is the point. Nobody is accountable for the books but you.

Tier 2: A contract or outsourced bookkeeper

The first real tier of help. At the basic level, this person categorizes transactions and reconciles your bank and credit card accounts each month. Rates for that scope in 2024 to 2026 run roughly $300 to $600 per month for a practice with moderate transaction volume, more as volume grows. A fuller engagement adds a monthly close, prepared financial statements, and accounts payable and receivable (AP/AR) support, and runs $1,500 to $3,000 per month for businesses in the $1M to $3M revenue range.

What this tier should produce monthly: every account reconciled, every transaction categorized, and a P&L and balance sheet delivered on a predictable date, not on request. If you are paying for the fuller scope, a real monthly close, meaning the numbers stop moving after it happens.

Not this tier’s job: interpretation. A bookkeeper who tells you your books are done is telling the truth even if the books cannot answer a single management question. The failure mode I encounter most often in this tier is a generalist bookkeeper who keeps technically clean books that are structurally useless, because the chart of accounts, the set of categories every transaction gets sorted into, was built for a generic small business. Clinician costs lumped into one payroll line. No service-line breakdown. Insurance revenue recorded when it arrives, with no way to see what it relates to.

One question filters for this well: has this person worked with insurance-based healthcare before? A bookkeeper who has not will sort your money into generic categories, and every tier above them inherits that structure.

Tier 3: An in-house finance person (full-charge bookkeeper)

At some point the practice brings this function inside. In my experience it is rarely a formal finance title. It is usually an operations or office manager, sometimes with a finance background, who took on the books, then payroll, and then some oversight of the billing function along the way. The role accretes rather than gets designed. The industry name for the accounting core of this job is a full-charge bookkeeper: one person owning transactions, reconciliation, payroll, and the monthly close, through to financial statements. The title rarely comes up in practice-owner circles, but it is the term a recruiter or a staffing firm will recognize.

For the formal title, salary aggregators put the median near $55,000, with Indeed showing an hourly range of roughly $19 to $37, while staffing-firm guides run $63,000 to $82,500 for experienced hires. Loaded with payroll taxes and benefits, plan on $65,000 to $100,000 per year. That cost is part of why the absorbed version of the role is so common: a dedicated hire is hard to justify when an outsourced firm delivers the same monthly package at $1,500 to $3,000, and most practices I work with in the $1M to $8M range run some combination of the absorbed role and an outsourced firm rather than a dedicated finance hire.

What this tier should produce monthly: a completed close by a fixed business day, full statements, payroll executed correctly, and, where the role includes billing oversight, a monthly view of claims and collections that connects to what hit the bank.

Not this tier’s job: forecasts, hiring models, or an opinion about your compensation structure. And if the role accreted rather than being designed, the job description conversation matters more, because nobody ever wrote one.

Tier 4: A fractional CFO

Two jobs live at this tier: the forward-looking work, and the design of the finance function itself.

The forward-looking work is where the unanswered-questions list finally has an owner: hiring break-evens, margin by service line and payer, owner compensation, cash forecasting, lease and expansion decisions. Per-clinician economics also live here, and they usually require combining the books with data from your practice management system (TherapyNotes, SimplePractice, or CentralReach, typically), because the P&L alone cannot see clinician-level productivity.

The design job is less visible. Someone has to decide how the chart of accounts is structured, what the close process is, and who owns what across the biller, the bookkeeper, and the CPA, and then stand accountable that the whole record can be trusted: by you, by a bank, by a buyer. At most practices I see, nobody holds that job. The lower tiers execute inside the system they were handed. This tier answers for the system.

Market rates for fractional CFO services cluster at $2,500 to $5,000 per month for businesses in the $1M to $5M range, with the broader market running $3,000 to $12,000 depending on scope and size. Published guidance places the need at roughly $2M to $10M in revenue, and healthcare-specific guidance moves that threshold earlier than for comparable professional services firms, because reimbursement timing and payer complexity punish blind spots sooner.

What this tier should produce monthly: a forecast that updates as reality arrives, margin visibility by service line and payer, a standing meeting where decisions actually get modeled, and a finance function that is designed, supervised, and trustworthy end to end.

Not this tier’s job: the bookkeeping itself. A fractional CFO builds on the tiers below. If the monthly close is unreliable, the CFO’s first months go to fixing the process rather than reading its output, so plan for that if you hire at this tier while the close is shaky. I wrote separately about how to tell whether you need this tier at all, including the honest cases where you do not.

Bookkeeper vs. in-house finance person vs. fractional CFO

Your CPA sits beside this table, not in it: returns, quarterly estimates, entity strategy, at every practice size.

Where the packaged services fit

A market of therapy- and ABA-specific financial services has grown up around these tiers, bundling several of them together, sometimes with the tax function included. They fall into three groups.

Software-led platforms for solo practices. Subscription products that combine automated bookkeeping with tax filing, typically priced between $100 and $300 per month. These are best understood as software with a thin layer of tier-two review attached: automation does the categorizing, humans check it, support runs through a messaging portal, and multi-owner practices are often excluded outright. At solo scale that trade is fair. The trouble starts when a growing group expects full tier-two or tier-three deliverables from a product built and priced for solo scale.

Therapy-specific accounting firms. A set of firms serves mental health practices exclusively, and several package their offerings as an explicit tier menu, from solo bookkeeping up through fractional CFO service. Among firms that publish pricing, the range runs from roughly $200 per month at the solo end to $4,000 and up for large multi-location groups with senior-level support, which lines up with the market rates above. Many in this niche quote privately instead, so use the published ranges as your reference point when evaluating a quote.

ABA-specific bundles. For ABA providers, a newer group of services bundles bookkeeping with billing operations, CFO-level advisory, and in some cases financing, often priced as a monthly fee or a percentage of collections. The pitch behind them is domain specificity, and it is a legitimate pitch: an ABA practice’s economics live in billable-hour percentages and payer-level margin, and a generalist who does not understand that produces confidently wrong numbers, which are worse than no numbers.

Whatever the package, the evaluation is the same: ignore the tier names on the pricing page and check which monthly deliverables from the table above actually arrive.

Setups that blur the tiers: CPA-kept books, billers, and the controller question

A few real-world arrangements do not fit the clean tiers. These are the setups where owners most often misjudge what they have.

The CPA firm that also does your books. Common and often fine, with one check: confirm what actually arrives each month. When this arrangement goes wrong, it goes wrong in a particular way. The firm keeps the books to support the tax return, so the chart of accounts mirrors the return: one salaries-and-wages line covering clinicians, admin staff, and the owner together; insurance revenue in a single deposits line; reconciliation done quarterly, when estimates are due. Every number is defensible for filing, and the owner still cannot see gross margin, cannot separate clinical labor from overhead, and is working from books that are up to ninety days stale. In my experience the bigger culprit is generic categorization rather than the tax orientation itself, but the test is the same either way: can the books answer a management question, or only support a return?

The controller question. In larger companies, a controller is the role that supervises the accounting function itself, checking that the close is accurate and the processes hold, sitting between the tier-three work and the tier-four forward work. Published guidance recommends that level of oversight somewhere between $1M and $5M in revenue, earlier for healthcare. I rarely see it as a distinct role at therapy or ABA practices in that range, though there is a selection effect in that: practices tend to call me precisely when nobody is playing that position. In this segment the controller function usually lives with the in-house finance person, the outsourced firm’s senior reviewer, or the fractional CFO engagement, and hiring a dedicated controller is rarely the next move.

The biller who does some of this. Billing companies increasingly offer bookkeeping add-ons. The revenue side of your books benefits from someone who understands claims. The expense side, payroll, and the close usually do not get the same attention, so treat a biller’s bookkeeping as partial tier-two coverage and check what is not covered.

The bookkeeper who grew with you. Some contract bookkeepers become the de facto finance person over years of tenure, and some are excellent. The risk is that nobody re-examines the scope: the practice grew, the deliverables did not, and loyalty keeps anyone from asking whether the monthly package still matches the business. Comparing what arrives each month against the table above is a kinder way to open that conversation than a performance review, because it puts the gap on the arrangement instead of on the person.

Five questions to find the tier you actually have

Answer these from observable facts, not from what the engagement letter says.

1. When did your last monthly close finish, and did the numbers stop moving afterward? If there is no real close, the close layer is unstaffed: you have basic tier-two coverage at best, whatever you pay for it.
2. Could anyone produce last month’s P&L broken out by service line, without a special project? If not, the chart of accounts was not built for management. That is fixable, and the fix has two parts: the rebuild is tier-two execution, but deciding the new structure is tier-four design work, and if nobody above the bookkeeper specifies it, you get the generic version again. Per-clinician numbers are a different matter: those usually come from your practice management system, not the books.
3. Who answered your last forward-looking question, and did the answer come with a model or an opinion? A tier-four answer has numbers attached.
4. Is anyone accountable for payroll, accounts payable, and the ledger as a complete cycle, or is it split across a biller, a bookkeeper, and you? Split coverage with no owner is the most common shape I find at growing group practices.
5. What do you pay in total each month for financial help, and what arrives in exchange? Write both down and set them against the table above. The gap between the two columns is the conversation to have.

What the answers point to: if the close is not real, or the cycle has no single owner (questions 1 and 4), the gap sits in the bookkeeping tiers: coverage or accountability, sometimes both. If the books cannot answer a management question (question 2), the chart of accounts needs a rebuild, whoever keeps it. If forward-looking questions have no owner (question 3), the top tier is empty, however good everyone below it is. None of these findings means firing anyone. Often the person is doing exactly what their tier does; the practice grew past the arrangement, and nobody decided that on purpose.

How to vet a bookkeeper or fractional CFO before you hire

Four questions do most of the vetting work, whichever tier you are hiring:

1. Ask for a sample monthly deliverable package: which statements, delivered by which business day. A vendor who cannot name specific deliverables now is unlikely to produce them later.
2. Ask them to walk through their month-end close checklist. Anyone selling full-scope tier-two work or above has one and can describe it without preparation.
3. Ask what insurance-based therapy or ABA practices they have worked with, and how they would structure a chart of accounts for one. You are listening for service-line thinking and clinician-cost thinking, not a memorized answer.
4. Ask what they would need from your current setup in the first sixty days. Good hires at every tier ask about the state of the tiers below them.

Run the five questions above before you change anything. Some owners will find the tier they are paying for is not delivering what that tier owes them, and the fix is a clearer agreement with the person they already have. Others will find the bookkeeping is fine and the missing piece is the forward-looking one; the fractional CFO article covers how to evaluate that hire, including the cases where the honest answer is not yet. And if the question you most want answered is a margin question, start with gross margin, the share of each revenue dollar left after paying the people who deliver care: that number is the one the upper tiers are hired to move.

Eastfield Consulting provides fractional CFO services to therapy and ABA practices. Its founder built and sold an EMR/RCM company, then led revenue cycle management at a major health tech company, before serving practices directly. If the five questions pointed at the top tier, the practice revenue check-up is a fifteen-minute way to see what a CFO would look at first, or you can book an intro call.