Financial leadership for South Carolina clinics scaling under one of the Southeast's more active CON programs

We are considering an ASC. How does South Carolina's CON program affect the financial plan?

The CON process can take six months to well over a year, can be contested by competing applicants (typically hospital systems or competing ASC operators), and creates real cash burn during the application window (legal fees, consulting fees, market analysis). Approval is not guaranteed. We model the application timeline, the cash burn through approval, the capital deployment if approved, and the alternative scenarios if the application is denied or delayed. The CON framework also affects exit valuation because a CON is a transferable asset in many transactions. Owners who treat CON as a paperwork exercise typically underestimate the project by six to twelve months and 15 to 25% on cost.

Should we make the South Carolina PTE election?

For most clinic owners with material South Carolina-source income, yes, but the math should be modeled annually. The PTE election converts non-deductible state income tax into a deductible business expense at the entity level, restoring federal SALT-cap deductibility. With the 6.4% top rate, the absolute dollar benefit is meaningful for high-income owners but is smaller than in higher-tax states. The election is irrevocable for the year it is made, so getting the timing right matters. We model it at the partner level because mixed-income partnerships do not all benefit equally.

Charleston is a concierge market. How do we structure the accounting?

Concierge and direct primary care revenue is recognized differently than traditional FFS. Membership fees are typically deferred and recognized over the membership period, even though they are collected upfront. That creates a deferred revenue liability on the balance sheet and a smoother monthly revenue recognition pattern. Practices we onboard frequently have been recognizing membership fees as revenue at collection, which overstates current-period revenue and understates the deferred liability. We rebuild the revenue recognition to match GAAP, which also makes the practice more defensible if a sale or partnership conversation happens.