The Business Side of Pediatric Practice
Pediatric practice management consulting starts with understanding why the economics differ from adult medicine. Nearly half of all children in the United States receive coverage through Medicaid or CHIP. That payer distribution shapes everything about how a pediatric organization operates, from which services generate margin to whether growth actually improves the bottom line.
SMCG works with pediatric practices and children's hospitals on the financial and operational questions that come with serving this patient population. We understand that the business model for children's healthcare requires different thinking than what works in adult primary care or specialty medicine.
Children's Hospitals and Pediatric Groups
Children's hospital consulting requires understanding how pediatric hospital operations differ from general acute care. The service mix, the payer contracts, the staffing models, the regulatory environment. All of it looks different when your patient population is exclusively under 18. SMCG provides consulting for children's hospitals and pediatric groups on the operational and financial decisions that determine whether an organization can sustain itself while meeting the healthcare needs of children in their community.
We work with hospital leadership on payer consulting for children's hospitals, including Medicaid managed care negotiations and commercial contract analysis. For multi-site pediatric groups, we address the operational questions that come with growth: how to maintain quality and culture across locations, how to structure compensation when payer mix varies by site, how to make acquisition decisions when the target practice runs on different economics than yours.
Payer Mix and Revenue in Pediatric Practice
The financial reality of pediatric practice looks different than most healthcare consultants assume. Your largest payer category often pays the lowest rates. Your vaccine program is a public health requirement that costs more to administer than it returns. These aren't problems you solve by seeing more patients or cutting staff. They're structural, and the planning has to account for that.
Medicaid-Dominant Pediatric Practice Economics
AAP analysis shows 49% of U.S. children are covered by Medicaid or CHIP. For many pediatric practices, that percentage runs even higher depending on geography and community demographics. Commercial payers might represent a smaller share of your patient volume while generating a disproportionate share of revenue. Understanding that imbalance matters for every decision you make: which locations to open, which providers to hire, which services to offer. We help pediatric organizations develop financial strategies that account for a payer mix where volume and margin don't align.
VFC Vaccine Program and Administration Costs
The Vaccines for Children program provides free vaccines to eligible children, but your practice still carries the overhead. Storage equipment, inventory management, staff time for administration, documentation for compliance. The administration fees paid by Medicaid often fall short of covering these real costs. Private practices participating in VFC face a gap between what vaccination actually costs and what it pays. Our revenue cycle team helps pediatric practices understand their true vaccination economics and identify where billing for administration can be captured accurately.
Pediatric Billing and Credentialing
EPSDT Compliance and Well-Child Visit Coding
Pediatric billing follows a cadence that adult primary care doesn't match. A child's first two years include more than a dozen recommended well visits according to the AAP Bright Futures periodicity schedule. Each visit carries specific documentation requirements for developmental screenings, growth measurements, and anticipatory guidance. For Medicaid patients, EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) requirements add another layer of compliance. Practices that don't bill these visits correctly leave money on the table or face recoupment later. Our billing team works with pediatric practices on well-child coding accuracy and EPSDT documentation.
Credentialing Across Pediatric Payer Networks
Adding a pediatrician or pediatric NP to your organization means credentialing with every payer you accept. For pediatric practices, that typically includes commercial plans, multiple Medicaid managed care organizations, and state CHIP programs. Some states require separate enrollment for VFC participation. A new provider who isn't fully credentialed can't bill for patients covered by those plans, which directly impacts revenue during the onboarding period. Our credentialing team handles pediatric payer enrollment across the range of insurance types your organization needs, tracking applications with managed care organizations and state programs to reduce the gap before new providers can see your full patient population.
What Generic Consultants Miss About Pediatrics
Most healthcare consulting firms treat pediatric practice as a subset of primary care. They apply benchmarks built for adult medicine. They recommend productivity targets based on specialties with different reimbursement structures. They suggest growth strategies without accounting for the fact that adding providers doesn't scale revenue when most new patients come from payers that pay less than cost.
A pediatric practice consultant needs to understand why the numbers work differently. The visit density is higher in early childhood. The documentation requirements for developmental screening exceed adult preventive care. The vaccine program is mandatory infrastructure that doesn't pay for itself. We approach pediatric consulting with these realities in mind, not as exceptions to general healthcare rules but as the foundation for how recommendations get made.
Schedule a Consultation
Talk with our team about your pediatric organization's financial challenges, credentialing needs, billing operations, or growth questions. We focus on the business realities specific to children's healthcare, not advice designed for adult medicine.
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