Most practice owners will evaluate exactly one set of construction bids in their career. The contractors pricing the work do this every week. Here is how to close that gap in an afternoon.
The lowest number is a claim, not a price.
When three bids land on a practice owner’s desk, the temptation is to treat them as three prices for the same thing. They almost never are.
Each number is a claim about scope: what that contractor believes the drawings require, what they included, what they quietly left out, and how much risk they priced. The real comparison is between scopes, and the estimate document is where a scope shows itself or hides.
This matters more in medical work than in ordinary commercial space, because clinical requirements, ventilation, plumbing density, power for equipment, code obligations, etc. are exactly the items a thin bid skips. The gap between a complete medical estimate and an optimistic one does not disappear when you sign. It comes back as change orders, on your schedule and your budget, after your leverage is gone.
Red flags you can spot in five minutes
A few patterns reliably signal a number you cannot trust, and none of them require construction expertise to see.
- A price that drops 10% or more with no change in scope. If the number can fall that far because you hesitated, the first number was padding or the second one is missing something. Either way you have learned how the contractor negotiates.
- Single-line subcontractor amounts. “Electrical: $180,000” tells you nothing about what the electrician included. A real estimate carries enough breakdown to show what is behind the trades that dominate medical work.
- No stated exclusions. Every estimate excludes something. One that does not say what it excludes has not told you where the gaps are, and the gaps are where the change orders live.
- Vagueness about what happens to cuts. When a low bidder trims to win, the cuts land somewhere, and they usually land on what you can see: the finishes, fixtures, and details your patients will look at every day.
Watch both outliers, not just the high one. Owners instinctively interrogate the expensive bid and celebrate the cheap one. Do the opposite as well: ask the low bidder what everyone else saw in the drawings that they did not, and ask the high bidder what they saw that everyone else missed.
A meaningful spread between bids means the bidders priced different projects, and you need to know which project is actually in the drawings. Sometimes the high bidder is the only one who noticed the structural work your imaging room requires; sometimes the low bidder has simply not priced it. Both answers are worth the ten minutes it takes to get them.
What a complete estimate itemizes
The rule that governs everything in an estimate is simple: not drawn means not priced. A contractor prices the documents in front of them, not the project in your head. If the drawings do not show it, it is not in the number, and the honest estimates say so in writing. That is why the inclusions and exclusions list is the most important page of the document, more important than the total.
The second thing to demand is a general conditions breakdown. General conditions are the costs of running the project itself: supervision, project management, temporary facilities, cleanup, safety, and the like. Thin bids bury them in a single line or scatter them invisibly through trade prices.
Our own bid summaries itemize general conditions line by line across pre-construction, construction, and post-construction, because an owner who can see what running the job costs can compare bids on substance instead of totals. Ask every bidder for the same breakdown, and note who resists.
Third, look for how the estimate handles what is not yet decided. Medical projects always carry decisions that come later: equipment selections, finish grades, owner-supplied items. A complete estimate names those open decisions and carries stated allowances for them, so you know which parts of the number are firm and which are placeholders that will move.
Understand how an allowance behaves, because it is the part of the number most likely to change. An allowance is a budget guess for something not yet selected: if the estimate carries an allowance for flooring and you later choose a product that costs more, the difference is added to the contract, legitimately. That is not a contractor failing; it is how allowances work.
What separates a fair estimate from a manipulative one is the realism of the guesses. A bidder can make a total look small by setting every allowance at the cheapest conceivable option, knowing your actual selections will cost more. Compare allowance values across your bids line by line, and ask any bidder whose allowances run noticeably low what those figures would actually buy.
The inclusions and exclusions list is the most important page of the document, more important than the total.
The owner-supplied equipment trap
Medical projects carry a scope seam that ordinary commercial work does not: the equipment the practice buys directly. Exam tables, sterilizers, imaging equipment, specialty casework, the owner often purchases these outside the construction contract, and that is where a predictable trap sits. The estimate covers the building; it may or may not cover receiving that equipment, setting it, connecting it, and standing behind the connection when something fails.
Force the seam into the open before signing. For every owner-supplied item, the estimate should answer four questions in writing:
- Who receives and stores it
- Who installs it
- Who provides the utility connections it needs
- Whose warranty covers what when it does not work
A related check applies to warranty scope generally: ask what the contractor warrants, for how long, and what falls to manufacturers or to you. None of these answers is expensive to get in writing before the contract, but all of them are expensive to discover afterward, usually the week the equipment arrives.
The equipment seam is also a drawings problem. An exam room sink is a construction decision, not a finish decision, because it drags plumbing, and plumbing dragged late reprices work that is already built. The more completely equipment is decided before pricing, the smaller this whole category of surprise becomes, which is a reason to resolve equipment selections before bids, not after.
The contingency line is a maturity test
Practice owners sometimes read a contingency line as an admission of sloppiness, as if a confident contractor would not need one. Lenders read it the opposite way, and the lenders are right.
Commercial lenders underwriting medical office construction commonly expect a contingency on the order of 8-10% as a condition of the loan, because they have watched what happens to projects without one. An estimate with no contingency is not braver; it has just moved the same risk into your change orders.
Lenders also quietly pad the construction schedule a contractor states before they set the loan terms, which tells you something useful: the people whose money is at stake assume estimates run long and cost more than stated. Build your own plan on the same assumption, and favor the bidder whose estimate already reflects it.
Questions that expose a thin number
You do not need to know construction to pressure-test an estimate. You need the questions that force scope into the open, asked of every bidder identically:
- What did you exclude, in writing, and why?
- What allowances are in this number, and what happens when an allowance is exceeded?
- Show me your general conditions as line items. What am I paying for you to run this job?
- What in the drawings is unclear or missing, and how did you price that uncertainty?
- If I asked you to cut this number by 10%, where exactly would it come from?
What this means for your next set of bids
Treat the estimate review as its own small project with its own afternoon on the calendar. Build a simple side-by-side: one row per scope area, one column per bidder, with the exclusions and allowance values called out where they differ. The exercise takes an hour with the documents in front of you, and it converts three incomparable totals into a picture of who priced what. Where a cell is blank for one bidder and filled for the others, you have found either a gap or a hidden assumption, and either one is a question worth asking before signing rather than after.
Then put every answer in writing. Scope clarifications that live in phone calls have a way of not existing when the change order arrives. The bidder who welcomes that scrutiny is telling you how they will run your job; so is the one who does not.
The estimate is the first deliverable a contractor ever hands you, and it is a sample of everything that follows: their thoroughness, their honesty about risk, and their willingness to show their work. A contractor who itemizes what running your job costs, states exclusions without being asked, and prices uncertainty out loud is showing you the project meetings you will sit in for the next year. Choose the number you understand over the number you like, and most of the expensive surprises in medical construction never reach you.
FAQs
Why is the lowest construction bid often not the cheapest?
Because bids differ in scope, not just price. A low number that excludes real scope comes back as change orders after signing, when competitive pressure is gone. The comparison that protects you is scope against scope, using each bid’s inclusions, exclusions, and allowances, not total against total.
What are general conditions in a construction estimate?
The costs of running the project itself: supervision, project management, temporary facilities, safety, and cleanup, as distinct from the trade work. A trustworthy estimate itemizes them so you can see what managing your job costs. A single buried line makes bids impossible to compare fairly.
How much contingency should a medical office project carry?
Commercial lenders financing medical construction commonly expect a contingency on the order of 8-10% and treat its absence as a red flag. Whatever the final figure, an estimate that carries no contingency has not eliminated the risk; it has moved it into your future change orders.
What does “not drawn means not priced” mean?
Contractors price the drawings they are given, not intentions. Anything absent from the documents, a wall relocation, an equipment circuit, a plumbing rough-in, is absent from the number. The defense is complete drawings and a written inclusions and exclusions list from every bidder before you compare.
