An inherited Google Ads account is a black box of decisions, configurations, and accumulated workarounds from people who are no longer responsible for it. Auditing it before changing anything is the single most valuable hour you can spend.
There is a particular moment in healthcare marketing that produces more waste than almost any other — the moment when one agency hands off a Google Ads account to another, or when a practice owner takes the account back in-house. Sometimes the handoff is amicable. Sometimes it is the result of frustration. Either way, the inheriting party usually does one of two things, and both are mistakes.
They either preserve everything in the account out of caution, leaving accumulated inefficiencies and questionable configurations in place because changing them feels risky. Or they tear everything down and rebuild from scratch, losing the historical data and accumulated learning that the account actually contained. Both responses are products of the same underlying problem — the inheriting party never properly audited what was there before making decisions.
A proper audit before any changes is the single most valuable use of time in this situation. It typically takes a few hours for an account of meaningful size, and it converts the account from a black box into a known quantity that can be improved with confidence.
Step 1: Confirm Access and Ownership
Before any analysis, confirm that the inheriting party actually has appropriate access. Many handoffs leave behind partial access — read-only when admin is needed, or admin transferred without removing the previous agency’s continuing access.
Verify that the practice owns the account at the Manager Account level, that the inheriting team has admin permissions, and that the previous agency’s access has been removed. Accounts where the previous agency retains access can be modified, exported, or even paused after the handoff, and this happens often enough to be worth checking explicitly.
Confirm that the linked accounts — Google Analytics, Google Business Profile, conversion tracking sources — are also under the practice’s ownership rather than the previous agency’s. These links can be the difference between an account that can be properly managed and an account where critical information lives in third-party properties the practice cannot access.
Step 2: Inventory the Campaign Structure
Begin with a high-level view of what the account contains. How many campaigns are active? How are they organized? What budget is allocated to each? Which are spending and which are paused?
Document this before changing anything. The structure itself is informative. Campaigns organized by service line tell you the previous agency thought in service-line terms. Campaigns organized by keyword theme suggest a different model. Many small campaigns with similar names often indicate someone has been creating campaigns reactively rather than maintaining a coherent structure.
Note the campaign types. Search, Display, Performance Max, Shopping if applicable, Video. The mix tells you what the previous agency was emphasizing and where they were experimenting.
Step 3: Examine Conversion Tracking
Conversion tracking is where most inherited accounts have hidden problems. Open the Conversions section and document every conversion action defined in the account.
For each conversion, note what it is supposed to track, when it was created, how it counts conversions, and whether it is currently firing. Conversions that have not fired in months are usually broken — the underlying tracking has stopped working — and any campaign optimizing toward them is operating on dead data.
Check the conversion values. Many accounts assign conversion values that no longer reflect the practice’s actual economics, or assign uniform values to conversions that have meaningfully different actual values. The bidding strategy is making decisions based on these values, and incorrect values produce incorrect optimization.
Look at the conversion attribution settings. Last-click attribution behaves differently from data-driven attribution, which behaves differently from position-based attribution. The reported performance metrics in the account depend heavily on this setting, and an account that switched attribution models recently will show data that looks inconsistent in ways that are not anyone’s fault.
Step 4: Review Search Term Reports
Pull the search terms report for the past ninety days. This is where the truth lives.
Search term reports show what queries actually triggered ads, as distinct from the keywords the account is targeting. The gap between targeted keywords and actual triggered queries is where most account inefficiency hides. Practices may be targeting clean keywords and still attracting irrelevant searches because of match types or weak negative keyword lists.
Look for patterns. Are job-related queries triggering ads? Are competitor brand searches triggering when they should not, or not triggering when they should? Are condition queries the practice does not treat triggering ads? Are queries from the wrong geography appearing? Each pattern is a fixable inefficiency once identified.
Note which negative keywords are missing. The negative keyword list, evaluated against the actual search terms, usually reveals gaps that have been costing budget for months.
Step 5: Audit the Negative Keyword Architecture
Look at the negative keyword lists at the account level, campaign level, and ad group level. Document what is there.
Most inherited healthcare accounts have less aggressive negative keyword coverage than they should. Common gaps include missing negatives for jobs and employment, missing negatives for unrelated specialties, missing negatives for free-service queries that do not match the practice’s offerings, and missing negatives for terms that have produced low-quality traffic historically.
Healthcare-specific negative considerations also include exclusions for conditions or services the practice does not treat, geographic terms outside the catchment area, and competitor terms that should be handled in separate dedicated campaigns rather than triggering generic ads.
Step 6: Examine Ad Creative
Pull a sample of the active ads across the account. Read them honestly.
Are the ads compliant with current platform policies, or do they include patterns that have become problematic since they were created? Are the headlines specific to the service and audience, or generic? Are the descriptions clear about what the practice offers and what the next step is? Are the calls to action appropriate?
Look at the asset experiments running, if any. Are different ad variations being tested, or has the account been running the same ads for months? Stagnant creative is a sign of inattention, even when performance looks acceptable.
Note any disapproved or limited ads. The disapproval history is informative — a pattern of disapprovals tells you the previous agency was operating close to policy boundaries, possibly without recognizing them.
Step 7: Review Bidding Strategy
For each campaign, note the bidding strategy in use and how long it has been in place. Bidding strategies have learning periods, and campaigns that have been switching strategies frequently are spending most of their time in learning rather than optimization.
Note whether the bidding strategy fits the campaign’s data depth. tCPA on a campaign with very few conversions does not work well. Maximize Conversion Value on a campaign without accurate conversion values is essentially Maximize Conversions with extra steps. The fit between strategy and data is one of the most commonly mismatched elements in inherited accounts.
Step 8: Check Geographic and Audience Targeting
Document the geographic targeting of each campaign. Where are ads being served? Does the targeting match the practice’s actual catchment area? Are there geographic exclusions in place, or does the targeting include areas the practice does not effectively serve?
Look at audience targeting and exclusions. Are existing customer lists being used in ways that touch the patient-list considerations addressed in Cluster 2? Are remarketing audiences configured appropriately? Are there demographic or in-market audience layers that should be reconsidered?
Step 9: Assess Landing Page Connections
Trace where each ad sends visitors. Are ads pointing to relevant landing pages, or to general practice pages that do not match the ad’s specificity? Are landing pages loading correctly? Are there ads pointing to pages that have been removed or relocated?
Broken or mismatched landing pages are surprisingly common in inherited accounts. The page existed when the ad was created, but the site has been redesigned since and the URL no longer works as intended. Each broken or mismatched connection is wasted ad spend.
Step 10: Compile Findings and Prioritize
After the audit, compile a list of findings organized by impact and effort. High-impact, low-effort fixes — broken conversion tracking, obvious negative keyword gaps, clearly mismatched landing pages — should be addressed first. Larger structural issues — campaign reorganization, attribution model changes, complete creative refreshes — can be planned over a longer horizon.
Communicate the findings to the practice owner before making large changes. Decisions about how aggressively to restructure an inherited account should involve the practice owner’s input, both because they are paying for the work and because they have institutional context the inheriting party does not yet have.
What This Audit Produces
By the end, the inherited account has been converted from a black box into a documented inventory. The inheriting team knows what is there, what is working, what is broken, and what needs to be changed. The first month of active management is then focused on the right priorities rather than on discovery.
The single hour or two invested in this audit typically saves weeks of trial-and-error and recovers spend that would otherwise continue flowing into the same inefficiencies that the previous agency left behind.
