What is discharge-to-bill time?
It is the number of days an account takes from the patient's discharge to submission to the health plan. The metric answers a simple question: once care ends, how long does the hospital take to bill?
Also called discharge-to-submission time, it covers stages 5 and 6 of the hospital revenue cycle: account closing and audit, then billing and submission. No health plan deadline is running in this segment. Every day of waiting comes from an internal pending item.
At hospitals in the National Association of Private Hospitals (Associação Nacional de Hospitais Privados, Anahp), health plans (operadoras) accounted for 76.47% of gross revenue in 2025 [2]. Health plans are regulated by the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar, ANS). Claims go out electronically in the TISS standard (Troca de Informações na Saúde Suplementar), the ANS data exchange standard. The Hospital billing pillar recommends measuring this interval separately, because it shows how much of the payment delay belongs to the hospital.
At Anahp member hospitals, average days to payment was 77.35 in 2025 [2]. That figure does not show how many days accounts spent inside the hospital before being billed.
An account goes through four milestones and three segments
An account changes status on four dates: discharge, closing, submission and payment. There are three segments between them, and only the last depends on the health plan.
See the segments as a table
| Segment | From | To | What holds the account | Who controls it |
|---|---|---|---|---|
| 1 | Discharge | Account closing | Medical record, charges, OPME, authorization, audit (DNFB balance) | Hospital |
| 2 | Account closing | Submission (protocol) | Health plan batch calendar, TISS XML validation (FBNS balance) | Hospital |
| 3 | Submission (protocol) | Payment | Health plan review, denial, appeal, payment | Health plan |
| Milestone | What it records | Where to find the date | Watch out |
|---|---|---|---|
| Discharge | End of care (inpatient stay) or of the billed period (interim bill) | Hospital management system; TISS admission or discharge notice, which must be electronic [7] | A discharge entered late in the system hides days of stalled account |
| Closing | Account reviewed, audited and ready to generate the TISS forms | Account status in the system | Use a single “closed” status; reopened accounts reset the clock |
| Submission | Account transmitted to the health plan in an XML batch | Batch protocol number and date | A rejected batch is not a submission; use the date of the accepted resubmission |
| Payment | Amount received and reconciled | Payment statement and bank record | Outside this metric; part of days to payment |
The first segment, discharge to closing, holds most documentation, charge capture and authorization issues. The second, closing to submission, depends on each health plan's submission calendar and on file validation. The third is the health plan's review and payment.
The Healthcare Financial Management Association (HFMA) splits the first two segments into two balances [1]. DNFB (discharged not final billed) covers discharged accounts without a final bill. FBNS (final billed not submitted) covers accounts already closed but held by pre-submission edits or rejected at transmission [1]. The guide Discharged not final billed (DNFB) covers those balances in reais and days of revenue.
How to calculate discharge-to-bill time
The calculation uses the accounts submitted in the period and each account's dates:
Average discharge-to-submission time (days) = sum of (submission date − discharge date) for accounts submitted in the period ÷ number of accounts submitted in the period
The formula is this guide's proposal, not an HFMA or ANS rule. HFMA has no per-account discharge-to-bill key. DNFB is a month-end snapshot of the balance, and charge lag (PB-4) measures the days between service and charge posting for each item [1]. What matters is writing the definition down and keeping it every month.
Four choices prevent misleading numbers:
- Mean and median together. A few very late accounts pull the mean up. The median shows the typical account; the gap between the two shows the size of the tail.
- Split by segment. Calculate discharge → closing and closing → submission separately. If the second is long, the problem is the batch calendar or file edits, not account review.
- Interim bills use the period date. The TUSS (Terminologia Unificada da Saúde Suplementar, the ANS unified terminology) classifies billing as interim, final, complementary or total (table 55) [8]. For an interim bill, use the end date of the billed period instead of discharge; measure complementary bills separately so late charges do not mix with normal closing.
- Read it with DNFB. The average only sees accounts already submitted. An account stalled for 60 days does not enter the calculation until it is sent; DNFB shows it today.
Illustrative example. In one month, a hospital submitted five accounts with 3, 4, 5, 6 and 32 days between discharge and submission. The mean is 10 days; the median, 5. The 32-day account, a stay waiting for an OPME (implants and special materials) invoice, more than doubled the mean on its own (without it, the mean would be 4.5 days). The split showed 27 days to closing and 5 to submission.
Why do accounts stall after discharge?
An account stalls because something is missing to close or submit it. Each cause shows up in one segment and has a different owner. The table lists those that often appear in hospitals that bill health plans.
| Cause | Segment | Owner | Practice that shortens the time |
|---|---|---|---|
| Discharge entered late in the system | Before closing | Inpatient units and admissions | Discharge recorded in the same shift and TISS discharge notice [7] |
| Incomplete medical record (progress notes, checked orders, operative report, discharge summary) | Discharge → closing | Physicians and nursing | Discharge checklist reviewed before the patient leaves |
| Late charges for supplies and drugs | Discharge → closing | Pharmacy, operating room, care units | Point-of-use charge capture; HFMA treats charges posted more than 3 days after service as late [1] |
| OPME without invoice, traceability label or authorization | Discharge → closing | Supply chain and authorization team | Item documentation checked in the operating room |
| Pending extension or authorization | Discharge → closing | Authorization team | Extension requested before authorized days run out |
| Medical team or physician fees not reported | Discharge → closing | Billing and medical staff | Team recorded from the surgical schedule |
| Internal audit queue | Discharge → closing | Internal audit | Concurrent audit during the stay |
| Waiting for the health plan's submission calendar | Closing → submission | Billing | Submission calendar by health plan with each cutoff date |
| Edits or rejection of the TISS XML batch | Closing → submission | Billing and IT | File validation before transmission |
Two causes deserve separate attention. The first is reopening: a closed account sent back for a pending item loses its place in the queue and adds days to both segments. Counting reopenings by reason shows where review is failing.
The second is long stays. Without interim billing, revenue from a stay of several weeks is billed only after discharge, and the large account takes longer to audit. When the contract allows it, interim billing brings billing forward; see the guide Interim billing.
Delay costs cash and can become a denial
Delay costs in two ways: idle cash and the risk of missing the submission deadline. Both grow with every day the account waits.
Idle cash. The hospital has already paid for the care, but billing has not started. On the ANS denial dashboard, average payment time is counted from the billing protocol, not from the date of care [6]. Days before submission do not appear in the health plan's numbers, but they weigh on the hospital's working capital.
Illustrative example. A hospital with gross health plan revenue of BRL 300 thousand per day cuts average discharge-to-submission time by 5 days. Cash receives a one-time gain of about BRL 1.5 million (5 × BRL 300 thousand). At a capital cost of 1% per month, that idle amount cost close to BRL 15 thousand per month. The guide Cost of payer delays shows the calculation with the hospital's own rate.
Submission deadline. Law 9,656/1998, art. 17-A, § 2, II, requires the contract between health plan and provider to set deadlines and procedures for billing and payment [3]. RN 503/2022, which regulates these contracts, sets no number of days for submission [4]. Each contract sets its own deadline.
When an account is submitted after that deadline, the health plan can issue a denial. TUSS table 38 has codes for this case. They include 3214, “billing outside the deadline set in the contract with the provider”, and 3161, “submission outside the contract period agreed between the parties” [5]. Anahp's contracting manual states that treating an account as time-barred because of late submission “has been considered illegal by the Judiciary” [9]. That is the association's position; in practice, the safest course is to submit on time.
Practices to close accounts faster
Closing accounts faster means clearing pending items before discharge and giving each remaining item an owner after it. These practices address both segments and can start without changing systems:
- Build the account during the stay. Concurrent audit reviews the account while the patient is in the hospital, so fewer pending items remain at discharge. See the guide Types of claims audit.
- Discharge checklist. Before the patient leaves, the unit checks the discharge summary, checked orders, operative report and OPME records.
- Daily queue by age and amount. Every day, the billing coordinator receives the list of discharged accounts not yet submitted, with discharge date, health plan, amount, segment and pending reason.
- Internal deadline by segment. The hospital sets how many days each area has to answer its pending item. The deadline comes from the hospital's own series and from the contract submission deadline, not from an external benchmark.
- Submission calendar by health plan. A table with each health plan's cutoff date, batch frequency and contract deadline keeps closed accounts from waiting for the next cycle without need.
- Validate the XML before the batch. Edits fixed before transmission avoid rejection and resubmission. See the guide TISS XML errors.
What is a good discharge-to-bill time?
There is no public benchmark. HFMA's MAP Keys page publishes no numeric target for pre-billing metrics [1], and in Brazil no primary source publishes an industry average for this interval.
The usable benchmark is the hospital's own, within two limits. The first is each health plan's contract submission deadline: the internal deadline needs a margin before it. The second is the hospital's own series: measure three months, split by segment and cause, and set a reduction target on the median.
What we see in operations
At Accrua, the stretch between discharge and submission is the first thing we measure, because it is the only one where the clock depends on the hospital alone. When we read a hospital's history, we split the two stretches this guide describes, discharge to close and close to submission, and look claim by claim at where the days pile up: OPME without an invoice or label, an incomplete medical record, a pending extension.
Accrua OS runs on top of the hospital's HIS/ERP and tracks each open claim against the submission deadline in the contract with that health plan. Agents handle what has a rule: XML validation, submission, deadline and status tracking. When a document is missing, the task goes to whoever can solve it, with the source shown.
In our managed operation, billers and auditors with nursing backgrounds work stalled claims by cause, not by arrival order. And when the issue is cash, Receita Garantida puts the value of eligible production into the hospital's account when it needs it.
Where to start
- Write the definition: which dates mark discharge, closing and submission, and how to treat interim bills, complementary bills and rejected batches.
- Calculate the mean and median for accounts submitted last month, splitting discharge → closing and closing → submission.
- Classify late accounts by cause and name an owner and an internal deadline for each.
- Build the submission calendar by health plan, with cutoff date and contract deadline.
- Track it weekly alongside DNFB and set the target from the first three months.