Who we serve
RCM for Hospitals and Large Medical Groups
Large groups face billing problems that small practices never see: dozens of providers coding differently, payer contracts that need monitoring line by line, credentialing rosters that never stop changing, and leadership that needs denial data by provider, site and payer. Hospital-based groups add the interplay between their professional claims and the facility's. We work with large multi-provider groups and hospital-based physician groups.
- Professional billing coordinated with facility billing
- Coding consistency and audits across specialties and sites
- Reporting built for leadership, not only for billing staff
Facility and professional billing compared
Groups working in hospitals bill the professional side while the facility bills its own. Both have to describe the same encounter.
| Area | Facility billing | Professional billing |
|---|---|---|
| Claim form | Institutional claim (837I, the electronic UB-04). | Professional claim (837P, the electronic CMS-1500). |
| What it covers | Room, nursing, equipment, supplies and other facility resources. | The physician's or practitioner's own services. |
| Coding | Revenue codes plus CPT, HCPCS and ICD-10 codes, and for inpatients, ICD-10-PCS procedures. | CPT and HCPCS with modifiers, and ICD-10-CM diagnoses. |
| Place of service | Defined by the facility type and bill type. | Paid at the facility rate under the Medicare physician fee schedule when furnished in settings such as a hospital, skilled nursing facility or ambulatory surgical center. |
Official sources: CMS MLN: Medicare billing, CMS-1450 and 837I (external site), CMS MLN: Medicare billing, CMS-1500 and 837P (external site), eCFR: 42 CFR 414.22 (facility practice expense) (external site), eCFR: 42 CFR 415.140 (split or shared visits) (external site), HHS-OIG: General Compliance Program Guidance (external site), eCFR: 42 CFR 401.305 (overpayments) (external site), UnitedHealthcare 2026 administrative guide (delegated credentialing) (external site)
Coding consistency across many providers
When dozens of providers document and code, variation is inevitable. Consistency comes from process.
Shared coding guidelines
Written rules for the group's common services, modifiers and documentation, by specialty.
Regular provider-level audits
Samples of each provider's claims reviewed against documentation, with results shared as education.
Outlier reporting
E/M level distribution and modifier use compared across providers in the same specialty.
Split and shared visit rules
Clear rules for visits shared by physicians and advanced practice providers in facility settings.
Managing payer contracts at scale
A large group may hold dozens of payer contracts, each with its own fee schedule, escalators and rules for specific services. Without contract terms loaded into the billing system, nobody can tell whether a payment is right, so underpayments are accepted as normal.
Contract management means loading each contract's rates, comparing every payment against them, disputing variances, and flagging contracts that are due for renegotiation, with the evidence to support it.
Denial analytics and reporting leadership needs
Denials by reason, payer, provider and site
So leadership can see whether a problem belongs to one clinic, one specialty or one payer.
Root-cause trends
Denials grouped by the step that caused them, from registration to documentation.
Contract variance reports
Expected versus actual payments by payer and service.
Productivity and charge lag
Charges and time to bill by provider, to spot documentation and charge capture delays.
Credentialing for groups that hire continuously
Step 1: Maintain one master roster
Every provider, location, NPI and payer enrollment in one place, updated with each change.
Step 2: Use delegated credentialing where available
Some payers, UnitedHealthcare among them, may delegate credentialing activities to a qualifying medical group or other entity that follows the payer's credentialing plan.
Step 3: Send roster updates on schedule
Additions, terminations and location changes are submitted to each payer in the format and timing it requires.
Step 4: Track revalidation and expirations
Licenses, certifications and payer revalidations are tracked across the whole group.
Compliance and audit readiness
A documented compliance program
Policies, training and auditing consistent with HHS-OIG compliance program guidance.
Audit trails for every claim
Who coded, edited and submitted each claim, and why.
Response process for payer and government audits
A defined process for record requests and audit responses, with deadlines tracked.
Overpayment handling
A process to investigate and return identified Medicare overpayments within the deadlines in 42 CFR 401.305.
System integration and account structure
Large groups often run several systems: a hospital EHR, a practice management system, a clearinghouse and separate analytics tools. Billing support has to fit into that environment, working through the interfaces and access the group already has rather than adding another system.
Groups of this size typically need a dedicated account structure: a named lead, specialty-trained billers and coders, and regular reviews with practice leadership. A dedicated account manager leads each large-group engagement, with regular reviews scheduled with your leadership.
Frequently asked questions
Do you bill for hospital-based physician groups?
Yes. We bill the professional side for hospital-based and large multi-provider groups, working in the systems and portals the group already uses.
How do professional and facility billing stay in sync?
Both sides describe the same encounter, so diagnoses, dates and procedures should match. Regular reconciliation between the group's claims and the facility's records catches missing charges and mismatches.
Can reporting be broken down by provider and location?
For large groups it should be, along with payer and denial reason, so problems can be traced to the right place. Our standard reports break results down by provider, location, payer and denial reason.
How is coding consistency kept across specialties?
Through shared coding guidelines, regular audits of each provider's claims, outlier reporting and education. Consistency is a process, not a one-time review.
What is delegated credentialing?
An arrangement in which a payer lets a qualifying group carry out credentialing activities under the payer's own credentialing plan. UnitedHealthcare's provider guide describes one example.
Services and specialties for this kind of practice
Related services
Revenue Cycle Management
The whole cycle run as one process: patient access, coding, claims, payments, denials and patient balances, with shared KPIs.
Learn more about Revenue Cycle ManagementCredentialing and Provider Enrollment
Medicare, Medicaid and commercial enrollment, CAQH upkeep and revalidation dates tracked so providers can bill from day one.
Learn more about Credentialing and Provider EnrollmentDenial Management
Denials worked by reason code and root cause, with corrected claims and appeals filed inside payer deadlines.
Learn more about Denial Management
Specialties
Anesthesia Billing
Base, time and modifying units, start and stop times, medical direction and concurrency modifiers, payer conversion factors and pain blocks.
Learn more about Anesthesia BillingRadiology Billing
Global, professional and technical component billing, imaging authorizations through benefit managers, contrast coding and ordering-provider rules.
Learn more about Radiology Billing
See where a large group's revenue is leaking
A free audit can start with one specialty or site and show denial and contract variance patterns before you decide anything.