Fractional CFO vs controller for healthcare practices
TL;DR: Controllers and CFOs solve different problems. A controller owns month-end close, internal controls, and the accuracy of the financial statements. A fractional CFO uses those statements to set pricing, model expansion, and stress-test the next twelve months of cash. Most clinics between $5M and $20M end up needing both. Below: what each role actually produces, what it costs, and how to tell which one your practice needs first.
Option A
Fractional CFO
Strategic financial leader focused on the future. Builds financial models, identifies growth opportunities, optimizes profitability, and prepares you for major decisions like expansion, acquisition, or exit.
Option B
Controller
Operational finance leader focused on accuracy. Manages the accounting team, ensures timely close, maintains internal controls, and produces reliable financial statements. The backbone of your finance function.
| Category | Fractional CFO | Controller |
|---|---|---|
| Primary focus | Forward-looking strategy. Where should we invest? What is our growth plan? Are we profitable enough to expand? | Backward-looking accuracy. Are the books closed? Are the financials correct? Are controls in place? |
| Typical cost | $4,000 - $8,000/mo fractional. $195,000-$270,000/yr full-time base. | $100,000 - $160,000/yr full-time. $2,000-$4,000/mo outsourced. |
| What they produce | Financial forecasts, cash flow projections, scenario analysis, board presentations, KPI dashboards, strategic recommendations | Monthly financial statements, reconciliations, internal control documentation, audit preparation, compliance reports |
| Decision-making role | Sits at the leadership table. Advises on pricing, staffing, capital allocation, and growth strategy. | Informs decisions with accurate data. Does not typically set strategy. |
| Growth planning | Builds the financial case for expansion. Models new location economics, analyzes break-even timelines, structures financing. | Ensures the accounting infrastructure can support growth. Sets up new entities, chart of accounts, intercompany accounting. |
| Exit preparation | Leads financial due diligence preparation. Builds the story buyers want to see in the numbers. | Cleans up the books and ensures GAAP compliance for due diligence review. |
A controller closes the books. A CFO tells you what the closed books mean for next quarter's decisions.
Do not confuse these roles. A controller who is asked to do strategy will give you recommendations built on an operator's view of the ledger. A CFO without a reliable controller function builds forecasts on numbers that will not survive an audit. Most clinics under $5M do not need a standalone controller; a solid outsourced accounting firm handles that function. Between $5M and $20M, most practices end up needing both: outsourced or in-house controller for operational accuracy, plus a fractional CFO for strategic leadership. The fractional model lets you get CFO-level thinking without paying a CFO-level salary.
Frequently Asked Questions
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