Billing for large groups and health systems

What does billing look like for a large group or health system?

It looks like many billing identities running at once: several tax IDs, several NPIs, several EHRs and a different set of payer rules for each site. The goal is one standard way of working across all of them, with reporting that rolls up. Each acquisition or new service line adds another identity to keep straight.

A multi-specialty group or health system also bills in two worlds. Professional services go on the CMS-1500 and facility services go on the UB-04, often for the same patient visit. Small mistakes in who is billing under which number are hard to see until a payer denies the claim.

How do multiple TINs and NPIs work in one group?

Each billing entity carries a TIN and an NPI, and the claim has to show the pair that matches its enrollment. CMS describes two NPI types: Type 1 for individual providers and Type 2 for organizations such as hospitals and physician groups, per the CMS NPI fact sheet.

The same fact sheet says individuals are only eligible for one NPI, while organizations can have multiple NPIs. Under 45 CFR 162.410(a)(1), a covered entity may also obtain an NPI for any other subpart that qualifies, so a system can hold separate numbers for separate units.

Three rules from the same sources are worth building into your checklist. Under 45 CFR 162.410(a)(4), a covered entity must tell the NPS about changes in its required data elements within 30 days of the change. An NPI is required for Medicare enrollment, but holding one does not enroll a provider with any health plan. And updating an NPPES record does not automatically update the provider's Medicare enrollment, so each record has to be changed on its own.

How does reassignment of benefits work, and is the CMS-855R still used?

Reassignment of benefits lets a group bill and be paid for a practitioner's Medicare services. The CMS-855R is no longer used: CMS merged it into the CMS-855I, and the current CMS-855I states that the CMS-855R form has been discontinued.

Under 42 CFR 424.80(a), Medicare does not pay amounts due a supplier under an assignment to any other person under reassignment, except in the cases the regulation lists. Two of the exceptions matter most to groups. Under 424.80(b)(1), Medicare may pay the supplier's employer when the supplier must turn fees over to the employer as a condition of employment. Under 424.80(b)(2), Medicare may pay an enrolled entity when there is a contractual arrangement.

The CMS-855 family of forms carries the paperwork. A practitioner can report a reassignment through PECOS or on the paper CMS-855I, and an organization that accepts, ends or changes a reassignment should also submit the 855I, according to the CMS bulletin on the consolidated form. On the 855I, reassignment information sits in Section 4F, with certification signatures in Sections 15B and 15C.

• Both the individual practitioner and the receiving organization must be currently enrolled, or enrolling at the same time, before a reassignment can take effect (CMS-855I instructions).
• A new reassignment needs the practitioner's signature in Section 15B and an authorized official of the organization in Section 15C.
• When a reassignment ends, claims for services the individual rendered are no longer paid to the organization after the termination effective date.

For a group that hires, acquires and loses providers every month, this is a standing workload. Each arrival and departure needs a reassignment filed or ended, or Medicare payments land in the wrong place or stop. Our credentialing and enrollment service covers the enrollment side.

Why does provider-based or freestanding status matter for billing?

Provider-based status decides whether a location is billed as part of a hospital or as a separate, freestanding facility. Under 42 CFR 413.65(b)(1), a facility is not entitled to be treated as provider-based simply because it or the main provider believes it is.

CMS has to determine that the facility meets the requirements in 413.65(d), which include licensure, integrated clinical services, financial integration, public awareness and the obligations of hospital outpatient departments. Under 413.65(d)(3), financial integration means the facility's financial operations are fully integrated into the main provider's financial system, with shared income and expenses.

Under 413.65(d)(4), a facility seeking this status must be held out to the public and other payers as part of the main provider, and patients must be billed accordingly. For a health system that buys a clinic and keeps its old name, signage and billing arrangement, that requirement is a billing question, not just a compliance one.

Where a facility treated as provider-based turns out not to qualify, 413.65 lets CMS adjust future payments to estimate what would have been paid to a freestanding facility. We do not decide a site's status for you. Your compliance counsel and the CMS determination do. Our part is making sure the claims match whichever status applies, as with hospital and facility billing.

How are split or shared visits billed across a large group?

A split or shared visit is billed by the practitioner who performed the substantive portion, under that person's NPI, with modifier FS on the claim. The MLN booklet on evaluation and management services says modifier FS tells the payer that 2 practitioners performed the visit even though the claim carries 1 NPI.

The visit is an E/M service in a facility setting performed in part by a physician and a nonphysician practitioner in the same group. Under 42 CFR 415.140(b)(2), the medical record must identify both, and the person who performed the substantive portion must sign and date it. For critical care, MLN says to report 99291, add 99292 units from 104 cumulative minutes, and add modifier FS.

In a large group the risk sits at the seams between teams. If the charge goes out under whoever opened the encounter, the NPI on the claim may not belong to the person who performed the substantive portion. The rule detail has its own page: see split or shared visit rules.

How do you standardize coding and reporting across many providers and locations?

You standardize by writing down one set of coding and charge-entry rules, applying it to every site, and measuring every site against the same few numbers. Reporting then has to roll up cleanly at three levels: group, location and provider.

A workable structure has a short list of fields every entity reports in the same way: entity (TIN and NPI), location, rendering provider, payer, and place of service. When every claim carries those fields, a director can see why one site has a lower clean claim rate than the group without rebuilding the data by hand.

The numbers we hold ourselves to are a 95% clean claim rate, claims sent within 24 hours of charge entry, and denials worked within 48 hours. Coding standards are backed by AAPC and AHIMA certified coders on our team, and billing and coding audits show where sites drift from the standard.

How do you manage payer contracting and credentialing for a large group?

Large groups usually carry several contracts, one per TIN or per acquired practice, with different rates and terms. Managing them means reading each contract against what the payer actually pays, and keeping every provider's enrollment tied to the right group.

Our payer contracting service checks remittances against contract terms and supports negotiation, and we never promise a rate increase. The credentialing service handles enrollment for new providers and new locations, and the guide on credentialing new locations lays out the order of work.

Systems with behavioral health programs can add a facility step. We get intensive outpatient and partial hospitalization programs approved and credentialed with commercial payers, at the facility level and at the individual provider level. See IOP and PHP credentialing.

The contract and the enrollment have to agree, so check each provider's group affiliation against the contract that governs payment.

What does moving a large group to an outsourced billing team involve?

It involves transferring work in a planned order, not switching everything on one day. The timeline depends on how many entities, EHRs and payers are involved, so we do not quote a fixed number of weeks before seeing your setup.

For an acquired practice the order of work is different again. See the acquisition billing integration guide.

How do we handle billing for large groups and health systems?

We work as the billing and revenue cycle team for hospitals, large groups and health systems. That covers revenue cycle management, professional claims on the CMS-1500, and facility claims on the UB-04, with the No Surprises Act work on top.

We align each EHR, clearinghouse and payer portal workflow with verified team experience, standard claim validation, reconciliation controls and performance monitoring. Automated eligibility checks are part of the workflow, and claims go through multiple scrubbing rules.

Every client has a Business Associate Agreement with us, all staff have HIPAA training and NDAs, and every system uses two-step login. See security for the full list. For management service organizations, our white-label billing runs under your brand.

Ready to talk through your entities and systems? Book a call.