Cost per lead is the wrong number in birth injury. Cost per signed case is the only one that reconciles.

Why the lead number lies

Cost per lead answers one question: how much media did we spend for each person who left contact details? In a practice where most inquiries become clients, that is a useful proxy for the cost of a case. Birth injury is the opposite kind of practice. A diagnosis is not negligence, a difficult delivery is not a breach of the standard of care, and firms that do this work well accept a small fraction of the families who contact them, after records review and expert consultation, months after the first call. Between the lead and the retainer sit several stages, and the drop at each one is larger than in any other plaintiff practice.

That makes cost per lead not just incomplete but manipulable. A vendor who halves your cost per lead by loosening the creative, bidding on medical-information searches or buying lower-intent traffic will often halve the share that survives your first screening conversation. The number they show you got smaller. Your cost of a signed case did not move, or went up, and your intake team spent the difference on calls that were never going to be cases.

The stages, defined in writing

The fix begins with definitions, not with dashboards. Every firm's funnel is slightly different, but a workable birth injury pipeline has at least these stages, each of which should be a status in your CRM with a timestamp on every transition.

• Inquiry. A call, form or chat that left usable contact details. Not an impression, not a click, not a bounced form.
• Contacted. A human spoke to the family. Voicemails and unanswered texts do not count. This is the stage where most accounts leak, and it is an operations problem wearing a marketing costume.
• Screened. The inquiry meets the written criteria your attorneys agreed to (jurisdiction, timing, the nature of the outcome, the providers involved) and records have been requested. If the criteria are not written down, this stage cannot be measured.
• Under review. Records and, where warranted, expert consultation. This stage has a cost per inquiry of its own, and it has a capacity limit.
• Signed. A retainer executed. The only stage that reconciles with the accounting system.

The arithmetic

With the stages defined, the computation is multiplication. Inquiries equal spend divided by cost per inquiry. Each subsequent stage multiplies by its conversion rate. The fully loaded cost per signed case is media spend, plus the review cost of every screened inquiry (including the ones that were not signed), plus the fees you want loaded, divided by signed cases. Here is a deliberately hypothetical month, chosen only to make the arithmetic visible.

Notice what the lead number hid. Cost per inquiry was $400. The thing the firm actually buys cost more than fifty times that, and most of the difference was decided after the click: by whether the phone was answered, by how well the first conversation gathered what review needed, and by how strict the criteria were. Now run the same month with a vendor who delivers inquiries at $250 but whose traffic screens at 8% instead of 15%. Inquiries rise to 120; signed cases fall to about 1.7; the loaded cost per signed case rises. The cheaper lead was the more expensive case. You can test any scenario you like in the cost per signed case model.

What the sensitivity usually shows

Add ten points to each rate in turn and watch the loaded cost. In most accounts we have run, the largest improvement comes from contact rate, because it is multiplied through every later stage and because it is usually the furthest from its ceiling. That is also the cheapest fix available: it costs nothing in media. After-hours coverage, a callback cadence, and a routing rule that puts a human on the line within minutes will move cost per signed case more than any bid strategy. Screened rate is the second lever, and it is improved by the quality of the first conversation and the exclusions in the search account, not by volume.

What to put on the report

One page, one set of definitions, printed on the page so that nobody has to remember them:

1. Spend, inquiries, contacted, screened and signed by channel for the month and cumulatively.
2. Media cost per screened inquiry and media cost per signed case.
3. Fully loaded cost per signed case, with review cost and fees shown separately.
4. Inquiries still in review and their median age, because this month's signed cases came from earlier months' spend.
5. The stage definitions, verbatim, and any change to them.

Two cautions

The lag is real. A birth injury signed in September may have been an August click and a June click. Report leading indicators (screened inquiries, records requested) alongside signed cases, and compute cost per signed case over a trailing window long enough to include the review cycle.

Capacity is a ceiling, not a rate. If screened inquiries exceed what your reviewers can absorb, the signed rate will fall and callbacks will slow. When that happens, spend is not the constraint, and scaling it will make the number worse. We cover the arithmetic of that ceiling in the intake capacity ceiling.