Fractional CFO for dermatology and med-spa
A fractional CFO for a dermatology or med-spa practice starts by recognizing you run two businesses under one roof: insurance-billed medical dermatology and cash-pay cosmetic and aesthetic work. They carry different margins, different collection cycles, and different marketing. A fractional CFO splits them into two P&Ls, then reads the numbers each one lives on: product and retail margin, provider versus injector productivity, device payback, and cash-pay versus payer AR. For a $5 to $50M practice, that is CFO-level judgment without a full-time hire.
Two businesses, two sets of numbers
Medical derm P&L, on its own
payer-billed visits, procedures, pathology
Aesthetic P&L, on its own
cash-pay injectables, devices, facials
Product and vial-level margin
cost per unit, yield, wastage, retail markup
Revenue per hour per provider and room
is the right person on the right work
Cash-pay vs payer AR
point-of-service cash vs aging denials
Device payback and room utilization
capital only earns when it runs
These are line items, not invented benchmarks. The Margin Map builds each one from your own practice data.
01 · Where the margin leaks
The financial problems specific to derm and aesthetics
A dermatology practice with an aesthetic arm is really two companies sharing a lobby. One sells expertise to insurers, the other sells outcomes to consumers for cash. Run them off one blended report and the leaks in each stay hidden behind the other.
Two businesses are blended into one blurry P&L
Medical dermatology bills payers for visits, biopsies, excisions, Mohs, and pathology. The aesthetic side sells injectables, laser and device treatments, facials, and skincare largely for cash. They have different margins, different risk, and different growth math. When they share one P&L, the strong side hides the weak side, and you cannot tell which business is funding which.
Injectable and retail product margin leaks by the vial
Neurotoxin and filler are inventory with real cost per unit, and yield per vial, wastage, and how units are priced against that cost decide whether the aesthetic line makes money. Skincare retail is either a margin line or an accidental loss leader, depending on markup, inventory discipline, and how loyalty and rewards credits are accounted for. Most practices never cost this at the unit level.
Provider and injector time is pointed at the wrong work
A physician doing routine cosmetic injections is expensive capacity spent on work a trained mid-level or injector could do, while the highest-acuity medical or surgical work waits. The question is revenue per hour per provider and per treatment room, and whether each person is deployed to the work only they can do. Without that view, the practice pays specialist rates for generalist output.
Two cash-conversion cycles get managed as one
Cash-pay aesthetics collects at the point of service: clean, immediate, no denials. Medical derm runs through payer AR with coding, denials, and aging. Memberships and treatment packages add deferred revenue that is collected up front and earned later. These are three different cash cycles, and running them off one blended AR report hides both the payer collection problems and the deferred-revenue liability.
Device and room capacity sit idle without anyone pricing it
A laser or energy device is capital that only earns when it runs. Its payback depends on utilization, price per treatment, and consumable cost. The same is true of every treatment room and chair. When utilization is not measured, the practice carries the cost of idle devices and empty rooms as if they were free, and books it to overhead instead of to the service line that should carry it.
Marketing spend is not tied to the margin it buys
Cash-pay aesthetics is a customer-acquisition business, and the spend on it should be judged against the margin and repeat revenue it produces, not against gross bookings. Medical derm grows on referral and reputation, which is a different engine entirely. Blended together, marketing looks either wasteful or free, and you cannot tell which channel is actually buying profitable patients.
02 · How the Command Center Method applies
What the Margin Map builds for a derm or med-spa practice
The Margin Map is a fixed $7,500 diagnostic over three weeks. For a practice that mixes medical dermatology and cash-pay aesthetics, it starts by pulling the two apart:
- 01
Two P&Ls, medical derm and aesthetics
Each business on its own statement, so you can see which one makes money, which one funds the other, and where each is leaking.
- 02
Product and vial-level margin
Cost per unit, yield per vial, wastage, and retail markup, so injectables and skincare are priced to earn instead of guessed at.
- 03
Revenue per hour by provider and room
Plus device payback and room utilization, so expensive capacity is pointed at the work that only it can do.
- 04
A short list of the biggest opportunities, priced
The Margin Map identifies at least $22,500 in margin opportunities, three times its fee, or you do not pay. Then the Command Center Method moves to Build and an Operating Cadence.
On independence
Koen takes no fee, commission, or referral cut from any device maker, product distributor, buyer, or billing vendor. The read on your two businesses is built for you, with no incentive to steer you toward anyone's product line.
03 · If a buyer or platform comes calling
Aesthetics platforms buy clean numbers
Dermatology and aesthetics have drawn steady consolidation interest, and a buyer will price the cash-pay side and the medical side on different terms. That makes the split P&L not just an operating tool but a diligence asset. A buyer's quality-of-earnings team wants recurring aesthetic revenue, device utilization, and membership deferred revenue shown cleanly, with owner compensation normalized and related-party arrangements at market.
Building the numbers that way early protects the multiple and keeps diligence from turning into a scramble. Josh has closed five sell-side transactions and was CFO of the Walter Reed Army Institute of Research, so the financials get built the way the buyer will read them.
See how this played out for a medical practice heading to exit.
Straight answers
Questions derm and med-spa owners ask
What does a fractional CFO do for a dermatology or med-spa practice?
Separates the two businesses you run, medical dermatology and cash-pay aesthetics, into two P&Ls, then builds the numbers each one lives on: product and vial-level margin, revenue per hour by provider and treatment room, device payback and utilization, and AR split between point-of-service cash and payer collections. The result is a clear read on which line makes money and where the margin is leaking, all for a fraction of a full-time CFO.
Why split medical dermatology and the med-spa into separate P&Ls?
Because they are different businesses with different economics. Medical derm is payer-billed, referral-driven, and governed by coding and collections. Aesthetics is cash-pay, marketing-driven, and governed by product cost, room utilization, and repeat visits. Blended into one statement, the profitable side masks the weak side and you cannot manage either. Split apart, each one can be run on its own terms.
How do we know if our injectable and retail pricing actually makes money?
By costing it at the unit level. Neurotoxin and filler have a real cost per unit and a yield per vial, and once you account for wastage and how you price against that cost, the true margin per treatment becomes clear. Skincare retail needs markup, inventory discipline, and correct handling of loyalty credits to be a margin line rather than a loss leader. The Margin Map builds that unit-level view from your own numbers.
Our physicians spend a lot of time on cosmetic work. Is that a problem?
It can be. The question is revenue per hour by provider and whether each person is on the work only they can do. When a physician runs routine cosmetic injections that a trained mid-level or injector could handle, the practice pays specialist rates for generalist output and delays the higher-acuity work. Looking at productivity per provider and per room usually surfaces a better deployment of capacity.
How should we think about memberships and treatment packages?
As deferred revenue. Money collected up front for treatments delivered later is a liability until it is earned, and it changes how you read cash and profit. Managed well, membership is recurring revenue that smooths the aesthetic side. Managed as if it were all current income, it overstates profit and hides a growing obligation. A fractional CFO gets that on the books correctly.
How much does a fractional CFO for a dermatology or med-spa practice cost?
It begins with the Margin Map, a fixed $7,500 diagnostic over three weeks. Ongoing work runs on a monthly retainer set well below a full-time hire. A full-time healthcare CFO costs roughly $275,000 to $500,000 all in; fractional work delivers comparable judgment in the $90,000 to $150,000 range a year.
Keep reading
Fractional CFO for medical practices
The full guide: what one does, when you need it, and how it differs from a bookkeeper or CPA.
Fractional CFO for physician groups
Provider-level profit, overhead allocation, comp models, and evaluating a PE LOI.
Fractional CFO for surgery centers
Margin per OR-hour, implant cost per case, and platform EBITDA vs owner distributions.
See which of your two businesses makes money
Three weeks, $7,500 flat. The Margin Map finds at least $22,500 in margin opportunities, three times the fee, or you do not pay. Retainer capacity is capped at 5 clients.