Engagements
Our clients commission the Operational QoE™ across the group's full lifecycle:
- A Portfolio Review of your existing locations
- Acquisition Diligence on what you acquire
- Pre-Listing then Going-to-Market engagements when you exit or transact with your next sponsor
The value of these four engagements is specific to whoever commissions it: a sponsor-backed platform, a doctor-owned group, or an advisor to the DSO.
Sponsor-backed platforms
When platforms work with us: a mandate to grow and a sponsor exit two to three years out; adding larger groups where the financial QoE alone leaves the price resting on trust; a board asking for operational detail the team cannot produce inside the diligence window; a lender asking for evidence that the patient base and the schedule behind the earnings will hold; the next sponsor asking what was actually captured after each acquisition.
Acquisition Diligence Operational QoE™
Fit. Platforms acquiring practices and small groups with outside capital behind them: private equity, a family office, or an independent sponsor. This includes invisible DSOs and doctor-led platforms where the partner dentists keep equity in their own practices, because the plan still has to satisfy an investor or a board.
Know how much opportunity sits in the target before you price it, in recoverable EBITDA, at a conservative rate and a moderate rate. Today the model carries a growth assumption, a percentage the deal team picks because nobody has measured the practice. The Operational QoE replaces that assumption with a quantified figure: recoverable EBITDA per location, converted on your own cost stack, shown at a conservative rate and a moderate rate. Your deal team underwrites on that figure and takes it to the sponsor and the lender with an independent document behind the case they were already making.
The same work shows how much of the practice's production depends on one provider, quantified as value at risk at your multiple. Standard diligence notes that as a flag; here it is a number, and it is deducted from the case rather than left for the credit committee to find.
Your integration team gets the findings before close and builds the value creation and integration plan from them, so capture starts the week you own the practice rather than after months of working out where the upside is. On a leveraged hold the IRR is time-weighted: EBITDA recovered in month two earns its multiple at exit and pays down debt for the whole hold, while the same EBITDA recovered in month twelve has already cost the platform ten months of cash and return. Run it on every acquisition and the platform builds something no DSO can otherwise show a buyer: what was found in each practice on the day it was bought, and what was captured afterwards.
In practice. Without it, the financial QoE confirms what the practice earned and the value creation plan still rests on a guessed growth rate. With it, the price rests on measured recoverable EBITDA, the sponsor approves capital with an independent document supporting the deal team's case, the lender sees the operational picture inside the credit file, and nobody on your side is surprised in month six by something the practice records showed all along.
“Our team was able to take that information and say, yeah, because of all this stuff this third party found, we agree, and we're gonna go do X, Y, and Z now. That would be powerful for our PE folks to see and hear early in the process.”CEO of a mid-sized DSO, on how his integration team would use the findings
“The work of discovering the opportunity that exists in those practices is largely left up to us post-close, and we're missing valuable time in that discovery process that we could have been executing on opportunity.”CEO of a 50+ location DSO in the South, on what his team inherits after close
Portfolio Operational QoE Review™
Fit. Platforms of any size, on the locations they already run.
Identify the opportunity in the locations you already own and what it is worth in recoverable EBITDA, location by location. Your CFO gets defensible data to underwrite organic growth against instead of a percentage in the model. Your board gets evidence the value creation plan holds, from an independent third party, and the operational questions that run back and forth between board and management have an answer. Your operations team gets clarity on which locations and which margin expansion levers to work first.
Recovered same-store EBITDA compounds across the rest of the hold, raises what the group can borrow for its next acquisitions, and proves the operating model the next sponsor pays a higher multiple for.
In practice. The organic growth line becomes a number the CFO can defend, the board's pressure eases because the plan has independent evidence behind it, the operations team stops guessing which location to work next, and the platform walks into its next financing and its next process with same-store growth it can prove.
“An independent source, just like with the financial QoE, where you could also do it in-house but the third party is worth it. The board might not trust it as much if it's coming from in-house than from an unbiased third party.”Founder of a PE-backed DSO, on why his board trusts an outside number
“It makes us more attractive to the next PE. One, we can execute earlier and with more confidence, and two, we feel and appear more buttoned up to whatever outside eyes, whether it's a lender or a future buyer or even our current PE folks. There's value in all of that.”Founder and CEO of a sponsor-backed DSO, on what the next sponsor sees
Pre-Listing Operational QoE™
Fit. Platforms 12 to 24 months from the sponsor's exit, with time to change the trailing figure the next buyer prices on.
Identify the opportunity the platform is leaving uncollected in its own patient base and what it is worth in recoverable EBITDA, then capture it into the trailing figure before the process opens. Your CFO gets the trailing EBITDA trajectory to the listing date, so the platform lists when trailing EBITDA peaks rather than when the hold period expires. Your operations team gets the recovery path, sequenced by location and by how soon each piece can be captured.
Every dollar captured before market earns its multiple at signing, and every dollar found but not yet captured is disclosed with its derivation, so the buyer's diligence treats it as upside they can verify rather than a weakness they can price down.
In practice. The next sponsor prices a trailing figure that includes the recovery, the uplift behind it is documented with its derivation, the process is timed to the number rather than to the calendar, and the buyer's diligence reads a position already on the record.
Going to Market Operational QoE™
Fit. Platforms at LOI with the next sponsor, with an earn-out or other contingent consideration on the table and no runway left to change the trailing figure.
Anchor the earn-out to operational assets that already exist across the platform, the accepted treatment and recall-due patients on the books, rather than to growth targets the buyer controls after close. Put the operational picture in the data room before the buyer's diligence writes its own version of it: a gap you have quantified gets priced for what it is, a gap the buyer discovers gets discounted far past its size. Counsel drafts the provision against a baseline fixed at a stated date.
In practice. The earn-out is drafted against assets on the books at a stated date, the buyer's diligence reads a baseline that was in the data room before it started, and you avoid re-trades, protect the valuation, and structure defensible deal terms.
What changes for each role
How the four engagements fit together: a 50-location platform adding 20 locations before a sponsor exit
A 50-location platform collecting around $100 million, with a mandate to add 20 locations over two years and a sponsor exit at the end of them. Conservative figures, for illustration.
- Portfolio review across the 50 locations. Roughly $2.9 million a year of recoverable production: lapsed patients nobody is reactivating, treatment accepted and never booked, a handful of locations whose providers sit well below the rest. Worked over a year and mostly captured, that lands as roughly $830,000 of recurring EBITDA through the platform's own write-offs, collection rate, and cost stack. At a 9x exit multiple, about $7.5 million of enterprise value from the locations it already owned.
- Acquisition diligence on the 20 add-ons. About $1.6 million of recoverable production across them, capturable from day one of each close and priced into the value creation plan the sponsor approves. It also catches the practices the financials flattered: a few whose active base has been shrinking behind fee increases and one or two whose new patients never come back, so the platform reprices those instead of paying for growth that is not coming.
- Pre-listing, at 70 locations. Another $2.5 million of recoverable production built up across the larger group, captured before market, lifting trailing EBITDA by roughly $750,000. At 9x, close to $7 million on the exit, from patients it already had.
- Going to market. The operational picture documented across all 70 locations before the buyer's diligence starts, and the earn-out drafted by counsel against assets on the books at a stated date. Avoid re-trades, protect the valuation, and structure defensible deal terms.
Without it: the $2.9 million stays invisible and drags earnings every year, the platform pays full price for the practices that were fading, it lists on lower earnings, and the buyer's diligence finds the undocumented gaps and grinds the price down anyway. Across one hold the difference runs well past $15 million.
Doctor-owned groups
When owners work with us: the first sponsor conversations have started; a bank, a specialty lender, or a non-control investor has begun asking for evidence that the patient base behind the earnings will still be there after close; a listing is 12-24 months out; or an offer is on the table and the earn-out is tied to growth targets you don't have control over.
Acquisition Diligence Operational QoE™
Fit. Doctor-owned groups buying one or two practices at a time on their own balance sheet, with no outside capital partner in the approval chain.
Know what the practice can actually produce before you pay for it. The seller shows you collections and an active patient count; the practice management system shows how many of those patients have not been back in a year, how much accepted treatment never got booked, and how much of the production sits with one provider who may not stay. The Operational QoE puts a dollar figure on each, from the practice's own records, so the offer price is set on what is there and your bank sees the operational picture beside the financials.
Without a corporate integration team, the document is your first-year plan: what to work on first, what is fragile, what to leave alone. The months after close go into capturing production rather than finding out what you bought.
In practice. You pay for what the practice can produce rather than for what the seller's summary implies, the loan is sized with the full picture, the first year is spent capturing the opportunity rather than discovering the problems, and every acquisition run this way adds to a record that speaks for the group when a sponsor eventually asks how it operates.
“It's not till you actually buy the practice and you start working in there for like six months to a year, when you see all the possible issues.”Doctor-owner, multi-location, has bought and sold
Portfolio Operational QoE Review™
Fit. Doctor-owned groups of three or more locations with no outside capital partner, where the owner still carries most of the operating decisions, with or without a small corporate team.
Identify the opportunity in each of your locations, what it is worth in EBITDA, and which locations and which levers to work first. It runs on its own or alongside the acquisitions you are making, so the locations you have are improving while you add more. Recovered same-store EBITDA raises what the bank will lend for the next acquisition and builds the operating record a sponsor asks for when the first conversation comes.
In practice. The group grows the locations it has while it adds more, the next loan is sized on higher earnings, and when a sponsor asks how the group runs, the answer is a document rather than a story.
“At that one, ten location, five location, you don't have a C-suite, you can't afford a C-suite, so you're trying to learn everything yourself.”Doctor-owner, multi-location, has bought and sold
Pre-Listing Operational QoE™
Fit. Doctor-owned groups 12 to 24 months from selling to an institutional buyer, with enough runway to raise the trailing EBITDA the buyer will price on.
Identify the opportunity in your locations and what it is worth in recoverable EBITDA, then capture it before you list. A practice sells for a multiple of trailing EBITDA, so every dollar recovered in the run-up is several dollars on the price, on earnings you improved. The trajectory to the listing date shows when trailing EBITDA peaks, so you list then rather than when someone else's timeline says so.
In practice. The sale is priced on earnings you improved, the buyer's diligence finds a position you have already documented, and the earn-out, if there is one, starts from a higher base. The difference between listing at half of what the group can do and listing near it is several times the recovered EBITDA, paid at close.
“You don't want to sell when you've seen 50 of your value. You want to push that number up. You'll never get to 100 because you'll always be chasing that. But you don't want to sell at 50 or 40, you want to get to 70, 80% of the value before you even go to market.”Former dental group CEO, exited by sale
Going to Market Operational QoE™
Fit. Doctor-owned groups at LOI with an institutional buyer, with an earn-out on the table and no runway left to change the trailing figure.
Anchor the earn-out to assets that already exist on your books, the accepted treatment and recall-due patients, rather than to growth targets the buyer controls once they own the practices. Put the operational picture in front of the buyer before their diligence builds its own version of it, so the gaps get priced for what they are instead of used to re-trade you at the closing table.
In practice. The earn-out is written against assets you already hold at a stated date, the buyer's diligence reads a position you documented first, and you avoid re-trades, protect the valuation, and structure defensible deal terms.
What changes for each role
Larger doctor-owned groups often carry a COO, a CFO, or a deal lead. Those seats read the same way as on the platform tab; the difference is who they answer to. There it is a sponsor and a board. Here it is the owner, and the owner is the one who has to live with the outcome.
How the four engagements fit together: a 12-location DSO, from expansion to exit
A 12-location group with around $24 million in collections, planning to expand for several years before a sale, with conservative figures for illustrative purposes.
- Portfolio review, with no transaction underway. Roughly $700,000 a year of recoverable production across the 12 locations: lapsed patients nobody is reactivating, treatment accepted and never booked, two locations whose providers sit well below the rest. The group works the roadmap over a year and captures most of it, and through its own write-offs, collection rate, and cost stack that lands as roughly $200,000 of recurring EBITDA. At a 7x exit multiple, that is $1.4 million of enterprise value created before expanding.
- Acquisition diligence on five practices. About $400,000 of recoverable production capturable from day one of each close. It also catches two things the financials hid: one target whose revenue looks steady while the active base has shrunk for two years behind fee increases, so the group reprices and restructures instead of paying for growth that is not coming, and one whose new patients are barely retained, so the group negotiates roughly $300,000 off the price.
- Pre-listing, two years later, at 17 locations. Another $600,000 of recoverable production built up across the larger group, captured before market, lifting the trailing EBITDA by roughly $180,000. At 7x, another $1.25 million on the sale price, from patients it already had.
- Going to market. The operational picture documented, so the buyer's diligence has nothing to discover and use, and the earn-out built on assets already on the books rather than promises about the future.
Without it: the $700,000 stays invisible and drags earnings every year; the group overpays on the fading practice; it pays full price for the treadmill practice; it lists on lower earnings; and at the closing table the buyer finds the undocumented gaps and grinds the price down anyway, comfortably another $500,000. Across one cycle the difference runs well past $3 million before counting the overpayment on the fading practice.
Advisors and lenders
When advisors and lenders work with us: a listing 12 to 24 months out where the trailing figure could be higher; a client at LOI with an earn-out on the table; a loan to size on a practice whose earnings depend on people the credit memo cannot see; a financial QoE that would be stronger with the operational layer beside it; or a client asking a question the P&L cannot answer.
Brokers, attorneys, lenders, bankers, and financial QoE firms commission the same four engagements on behalf of a client, or bring DRAI into a transaction they are already advising on. What changes is who holds the relationship and how the document is delivered.
Acquisition Diligence Operational QoE™
Fit. Lenders sizing a loan on the practice being bought, bankers advising the buyer, and financial QoE firms delivering beside their own report.
For a lender, the credit memo tells you what the practice earned. It does not tell you what the borrower can earn from it once they own it, or how much of those earnings depend on one provider who may leave. The Operational QoE answers both from the practice's own records: the recoverable revenue in the patient base, converted to EBITDA on the borrower's cost structure, and the share of production at risk if the key provider goes. That is a loan sized on what the practice can actually produce, with the operational picture in the credit file beside the financials, and a documented reason behind the growth the borrower is projecting.
For a financial QoE firm, the report sits beside your bridge on the same data room access without duplicating a line of it. Your work confirms what was earned; ours quantifies the opportunity that never reached the top line. Delivered together, the buyer gets one package that covers both the history and the upside, and your firm is the one that brought it.
The gap is real, and it is not a criticism of anyone. Here is how the operational side of a dental acquisition usually gets looked at today, in the words of a healthcare banker who sees the buy side every week. A production report is a printout from the practice management system; it says what was produced, not what the patient base could produce or why it did not.
“They will ask for a production report. They'll just print from a PMS, and that's pretty much it. And then they will sit down and figure out, well, what's the potential for us, what's our projection model look like, making sure that doctor stays, and so on. Very bread and butter.”Healthcare M&A banker at a global bank, on how thin the operational read on a dental deal usually is
In practice. The lender underwrites on a measured figure rather than a printout, the borrower's projection has a documented source the credit committee can check, key-person risk is known before it is priced in, and the QoE firm delivers a fuller package than it could alone.
Portfolio Operational QoE Review™
Fit. Fractional CFOs, exit planners, and lenders with a group on the books, at any stage: years from a sale, or with no sale in view at all.
For a fractional CFO or exit planner building an earnings plan for an owner, the review is the measured base under it: the recoverable opportunity in each location, what it is worth in recurring annual EBITDA, and which locations to work first, produced by an independent party rather than assembled from the owner's own dashboards. The plan you take to the owner rests on a number someone outside the group put their name to, which is a different conversation from one built on estimates.
For a lender, it is a documented operational picture beside the covenants you already track: whether the earnings are spread across the locations or held up by two or three of them, whether the patient base is growing or quietly shrinking behind fee increases, and how much production sits with one provider. Those are the questions that decide whether a facility gets renewed at the same size or a larger one, and today they are answered from the P&L, which cannot see any of them.
In practice. The CFO's plan carries an independent number, the owner works the locations with the most recoverable EBITDA first, and the lender renews or expands the facility with the operational picture in the file rather than a good feeling about the borrower.
Pre-Listing Operational QoE™
Fit. Brokers and transition advisors with a client 12 to 24 months from listing.
This is the engagement you hand an owner before the practice is ready to list. It identifies the opportunity sitting in the patient base, what it is worth in EBITDA, and how much of it can realistically be captured into the trailing twelve months before the listing date, so the owner and their team have a clear roadmap to raise the number the listing will be priced on. We measure and sequence it; the owner's team captures it.
The difference for you as the broker is the number you take to market. A group listed on trailing EBITDA that has been raised through documented recovery, with the rest of the opportunity written up for the buyer, lists higher and holds its price through diligence, because the buyer's diligence team finds the recent growth already explained rather than a spike it has to discount. A higher listing that survives diligence is a larger closing, and the commission is calculated on the number that closes.
In practice. Your client lists on a higher trailing figure with the cause behind it written down, the buyer's diligence has a source to verify instead of a gap to price, the re-trade conversation has less to feed on, and the deal is likelier to close at the number it was listed at.
Going to Market Operational QoE™
Fit. Deal attorneys drafting the purchase agreement, and bankers running the sale process, with a client at LOI.
Most earn-outs are tied to future growth targets the seller no longer controls once the buyer owns the practice, and that is the reason so many end in dispute. This engagement documents what the seller has already created and not yet collected: the accepted treatment plans never scheduled and the patients due back who never returned, counted from the practice management system and fixed at a stated date. Those are the operational assets: revenue that already exists in the patient base, with a name and a date on every figure.
For counsel, that gives contingent consideration something specific to attach to. The earn-out is drafted against documented patients and treatment that both sides can count, rather than a projection either side can argue about, and the seller makes their disclosures against a written baseline. For a banker running the process, the same document goes into the offering materials so the buyer's diligence reads the operational picture the seller documented first, with the source behind every figure, instead of building its own version and using it to move the price.
“Buyers are creative in saying, okay, if you're saying that you're going to get to 2 million EBITDA, then prove it. The proof will be in an earn out. And up until now there hasn't been a bridge that's shown, here's the how of earning that earn out.”Outsourced CFO director at a dental advisory firm with an in-house financial QoE team, on the bridge from operations to earn-out that the Operational QoE now provides
In practice. The earn-out is written against assets that exist at a stated date, the seller's disclosures have a documented basis, the buyer's diligence finds the position already on the record, and the price agreed at LOI is defended with evidence rather than argument.
What changes for each advisor
DRAI produces the document and works alongside the client's existing advisors. The deal, the structure, the implementation, and the mandate stay with you. Brokers get stronger sell-side numbers and fewer renegotiations; attorneys get earn-outs and deal terms anchored to documented operational assets that hold up when challenged; lenders get a clearer operational picture to underwrite against; QoE firms get the operational layer beside their own.
Brokers and transition advisors
A listing is a narrative about a practice, built on financials and on what the seller says. What the practice management system shows about recall, unscheduled treatment, and provider dependence has not been part of that narrative, because nobody has pulled it into a form that belongs in a data room. With a Pre-Listing engagement 12 to 24 months out, the seller's own team works a roadmap we sequence for them, so recoverable revenue lands in the trailing figure before the listing is priced. With a Going to Market engagement at LOI, the gaps a buyer would otherwise discover are already documented, so the re-trade conversation has nothing to feed on. Either way the broker is defending a number with a documented source behind it, and the deal is likelier to close at the number it was listed at, under favorable terms for their client.
Deal attorneys
Earn-outs usually hang on future performance the seller no longer controls, and the ones that end in dispute are the ones drafted against a projection. A Going to Market engagement documents the revenue the seller has already created and not yet collected, the accepted treatment never scheduled and the patients due back who never returned, counted from the practice management system and fixed at a stated date. Those are the operational assets, and each carries a definition either side can re-run. Contingent consideration then drafts against something both parties can count rather than a projection either can dispute. We document the assets; counsel structures the provision.
Lenders and bankers
A credit file sized on trailing earnings answers what the practice earned. It does not answer what the borrower can earn once it owns the practice, or how much of the earnings sit with one provider. At least one national lender has started asking for active patients, recare, forward booking, and receivables on sub-$1 million deals; the Acquisition Diligence engagement answers those questions directly from the practice management system, inside the same window as the financial QoE, so the credit committee sees a measured figure with its source rather than an assertion. For investment bankers running a platform process, the same document goes into the offering materials, so the operational picture the buyer's diligence would otherwise build for itself is already there, with a source behind every figure, and the process is defended from evidence rather than from the management presentation.
Financial QoE firms, CPAs, and fractional CFOs
Delivered beside your report, on the same data room access, without duplicating a line of it. Your bridge normalizes what the practice earned; ours quantifies the opportunity that never reached the top line, because the patient never came back or the plan never got scheduled. Together the buyer gets one package that covers both the history and the upside, and your firm is the one that delivered it. For a CPA or fractional CFO advising an owner, the same report is the measured base under the earnings plan you build for them, produced by a party the other side will accept. Referrals run both ways.
“That's a metric that the intelligence platforms of the world have pretended to have for years, but no one has believed it, because they couldn't do a good job measuring it.”Outsourced CFO director at a dental advisory firm with an in-house financial QoE team, on measuring recoverable revenue
Referrals and introductions
An engagement can run either way. Through you: you hold the relationship, the finished document comes to you, and you deliver it to your client inside that relationship, signed by DRAI so the independence holds with the other side. Or direct: you introduce the group, we scope and contract with them ourselves, and you are kept informed throughout. Referral arrangements are available to brokers, attorneys, lenders, bankers, and diligence firms who introduce engagements.
How the four engagements fit together across a group's life, and who reads each one
A 12-location doctor-owned group with around $24 million in collections, advised over one cycle by the people on this page. Conservative figures, for illustration.
- Portfolio review, commissioned through the group's fractional CFO, with no sale in view. Roughly $700,000 a year of recoverable production across the 12 locations, converted through the group's own write-offs, collection rate, and cost stack to about $200,000 of recurring EBITDA, most of it in three locations whose recall had lapsed after a manager left. The CFO builds the earnings plan on a base someone outside the group has put their name to, the owner's team works the three locations first, and the group's lender renews the facility with the operational picture in the file.
- Acquisition diligence on the next five practices, with the lender in the room. About $400,000 of recoverable production capturable from day one of each close. The lender sizes each loan on what the borrower can earn once it owns the practice, with provider concentration disclosed before the credit committee asks. Two targets the financials flattered get repriced, and the group's financial QoE firm has the operational layer beside its own bridge on every deal.
- Pre-listing, eighteen months before market, introduced by the broker. Unlike the portfolio review, this one is aimed at a date. It identifies another $600,000 of recoverable production across the larger group, models how much of it can land in the trailing twelve months before the listing, and sequences the capture to that clock. Trailing EBITDA rises by roughly $180,000 in time to be priced. At 7x, about $1.25 million on the asking price, and the broker lists a number whose recent growth has a written explanation the buyer's diligence can verify.
- Going to market, at LOI, with counsel drafting. The remaining position documented as assets at a stated date. The attorney anchors the earn-out to accepted treatment and recall already on the books, the buyer's diligence finds nothing to reprice, and the buyer's lender and QoE firm read the same document from the other side. The broker holds the number through diligence instead of renegotiating it.
Without it: the CFO's plan rests on the owner's dashboards, the lender sizes each loan on trailing earnings alone, the broker lists on a lower figure with an unexplained growth spike for the buyer to discount, and counsel drafts the earn-out against a projection that ends in dispute. Same group, same advisors, same practices. Across the cycle the difference is the price the client gets and the terms it gets it on.