What does discharged not final billed (DNFB) mean?
DNFB accounts are those of patients who have been discharged, whose care is over, but whose bill has not yet been finalized and sent to the health plan (operadora). The term is used by the Healthcare Financial Management Association (HFMA) in its MAP Keys, a set of standard revenue cycle KPIs [1]. In Brazil it is used as is or translated as contas não faturadas (unbilled accounts).
It is the KPI that measures revenue earned and stuck inside the hospital. The cost of care has already been paid (staff, supplies, drugs), but billing has not even started. That is why the problem does not show up in denials or overdue receivables: it shows up only when cash runs short.
Among the 20 KPIs in the Revenue cycle KPIs guide, DNFB sits in the account closing group, next to discharge-to-submission time. It is one of the few KPIs the hospital controls almost entirely.
How HFMA defines and calculates DNFB
HFMA defines DNFB as a trending indicator of the claims generation process, measured in days of revenue [1]. The MAP Key PB-1 formula is:
DNFB days = gross amount of discharged, not final billed accounts (month-end snapshot) ÷ average daily gross revenue for the month
The denominator is the month's gross patient service revenue divided by the number of days in that month. HFMA specifies a single-month daily average, not a three-month rolling average [1].
| Element | HFMA rule (PB-1) [1] | Practical equivalent in a Brazilian hospital |
|---|---|---|
| Numerator | Gross A/R for inpatient and outpatient accounts discharged and not final billed, at month-end | Accounts of discharged patients not yet sent to the health plan, at contract prices |
| Included | Recurring accounts (interim bills), accounts discharged and held during a system suspense period, ambulatory services charged but not final billed (held in suspense), late charges generated for accounts in DNFB status | Accounts being closed, in pre-billing audit, or waiting for documents, authorization, length-of-stay extension, OPME invoice or physician fee data |
| Excluded | In-house accounts; final billed accounts held before submission (FBNS); late charge bills | Patients still admitted; closed accounts waiting for the batch or stuck in XML validation (measured separately) |
| Denominator | Month's gross patient service revenue ÷ days in month | Month's gross revenue (from health plans only, if the KPI covers only health plans) ÷ days in month |
| Frequency | Monthly snapshot | Monthly snapshot for the series; daily tracking in operations |
The right-hand column is this guide's proposed adaptation, not an HFMA rule. What matters is to pick one version, write it down and keep it every month.
HFMA also defines two neighboring KPIs. FBNS (final billed not submitted to payer) measures accounts already finalized but held by edits before submission. DNSP (discharged not submitted to payer) adds DNFB and FBNS, over the same denominator [1]. In Brazil, FBNS corresponds to closed accounts waiting for the TISS batch or returned for file errors, covered in the TISS XML errors guide.
View text description
- Patient discharge → final bill: DNFB, inside the hospital. Patients still admitted are excluded.
- Final bill → submission to the health plan (operadora): FBNS (batch and XML validation).
- DNSP = DNFB + FBNS.
- Submission → payment: days to payment (prazo médio de recebimento).
- DNFB days = gross amount of discharged, not final billed accounts (month-end snapshot) ÷ (month's gross revenue ÷ days in month). Illustrative example: BRL 2.4 million ÷ BRL 300,000 per day = 8 days.
Why measure in days and not only in reais?
Days allow comparisons across months and across hospitals of different sizes. The value in reais (BRL) rises and falls with admissions and case mix; days show how much of production is stuck, relative to what the hospital bills.
Illustrative example. A hospital had BRL 9 million in gross health plan revenue in a 30-day month, or BRL 300,000 per day. On the last day of the month, BRL 2.4 million sat in discharged accounts not yet sent. DNFB was 8 days (BRL 2.4 million ÷ BRL 300,000). If the hospital gets to 5 days, it frees BRL 900,000 of cash once. At a cost of capital of 1% per month, that BRL 900,000 of idle cash costs about BRL 9,000 per month.
The value in reais still matters day to day: the daily list should be sorted by the largest and oldest accounts. The cost of idle cash, at the hospital's own borrowing rate, is covered in the Days-to-payment calculator and in the Cost of payer delays guide. When you add the cost of DNFB to the cost of days to payment, check where the clock starts: the sum only works when days to payment is counted from the invoice date, as Anahp's is. If it is measured from discharge, the days before billing are already in it and would be counted twice. The guide Revenue cycle ROI builds that calculation without double counting.
DNFB, discharge-to-submission time and days to payment
The three KPIs measure different stretches of the account's path. DNFB is a balance (how much is stuck right now); discharge-to-submission time is an average lag (how long the accounts sent took); days to payment (prazo médio de recebimento, PMR) covers billing to payment.
| KPI | What it measures | Stretch | Who controls it |
|---|---|---|---|
| Discharged not final billed (DNFB) | Balance of discharged accounts not yet sent, in reais and in days of revenue | Discharge to final bill | Hospital |
| Discharge-to-submission time | Average days between discharge and submission for accounts sent in the period | Discharge to submission | Hospital |
| Days to payment (PMR) | Accounts receivable ÷ revenue for the period × days | Billing to payment | Hospital and health plan |
Days to payment is calculated on accounts receivable, and an unbilled account is not there yet. At Anahp member hospitals, it averaged 77.35 days in 2025 [2]. That figure does not include the days each account spent inside the hospital before billing. The Hospital days to payment guide details the formula and the four stretches of collection.
For the same reason, DNFB stays out of billed aging. HFMA keeps the measures apart: billed A/R aging (AR-1) excludes discharged accounts not yet billed, which enter only the total view (AR-3) [1]. The breakdown by age bracket is in the guide Payer A/R aging.
The two internal KPIs complement each other. Discharge-to-submission time only sees accounts that went out; an account stuck for 60 days stays out of the average until it is sent. DNFB sees that account today.
Why accounts stall after discharge: the most common causes
Accounts stall because something is missing to close them safely. Each reason has a different owner, so DNFB must be broken down by hold reason, not just summed. The table lists reasons that often come up at Brazilian hospitals serving health plans.
| Hold reason | Typical sign | Who fixes it | How to prevent it |
|---|---|---|---|
| Incomplete clinical documentation | Missing progress notes, checked prescriptions, operative report or discharge summary | Medical and nursing staff, with billing following up | Chart check in the first hours after discharge |
| Late charges for supplies and drugs | Usage recorded after discharge or not posted to inventory | Pharmacy, operating room and care units | Point-of-use charge capture and daily reconciliation with inventory |
| Implants (OPME) without paperwork | Missing invoice, traceability label or item authorization | Purchasing and authorization desk | OPME checklist before surgery |
| Pending authorization or extension | Procedure or daily rates without a valid authorization number | Authorization desk | Concurrent review and extension requests before authorized days run out |
| Pending physician fees | Team not reported or not registered with the health plan | Billing and medical staff | Team registration in the surgical schedule |
| Pre-billing audit queue | Account ready, waiting for review | Internal audit | Size the team to discharge volume and audit during the stay |
| Manual closing and short staffing | Accounts stalled with no technical issue | Billing coordination | Queue by value and discharge date, with a daily target |
Two situations deserve separate attention. The first is long stays: under HFMA's rule, in-house accounts are excluded from DNFB [1], so the revenue of a 40-day stay appears only on discharge day. Interim billing (conta parcial), where the contract allows it, brings part of that billing forward, and HFMA does include unbilled recurring (interim) accounts in DNFB [1]. See the Interim billing guide.
The second is the discharge notice. Under the TISS standard, admission and discharge notices must be electronic [5]. If discharge is not recorded in the system on time, the account does not enter the closing queue and DNFB looks smaller than it is.
A stalled account is also a denial risk
Delay costs more than idle cash. Brazil's health plan law, Lei 9.656/1998 (Law 9,656/1998), art. 17-A, § 2, requires the contract between health plan and provider to set deadlines and procedures for billing and payment [3]. When an account is sent after the agreed deadline, the health plan can deny it with code 3214 of TUSS table 38, “cobrança fora do prazo estipulado no contrato com o prestador” (billing outside the contract deadline) [4].
According to Anahp's contracting manual, time-barring an account for late submission “tem sido considerada ilegal pelo Poder Judiciário” (has been considered unlawful by the courts) [6]. That is the association's position, not a general rule; in practice, the hospital avoids the dispute by billing on time. The clauses the contract should include are covered in the Payer claim submission deadlines guide and in the Hospital billing guide.
How to reduce discharged not final billed accounts
Reducing DNFB means organizing the closing queue and tackling the cause of each hold. These steps are operational and can start without changing systems:
- Daily list by reason. Every day, billing coordination gets the discharged accounts not yet sent, with value, discharge date, health plan and hold reason.
- Age buckets. Split accounts by days since discharge (for example, up to 3, 4 to 7, 8 to 15, 16 to 30 and over 30 days). The buckets are a suggested way to organize the list, not an industry reference.
- Priority by value and age. Largest and oldest accounts go first, and those close to the contract submission deadline go before all others.
- An owner for each hold. Each reason has an owner and a response time agreed with the area (medical staff, pharmacy, purchasing, authorization desk).
- Audit during the stay. Concurrent review resolves issues while the patient is still in hospital, so the account reaches discharge nearly ready.
The Hospital revenue cycle guide shows where each step fits in the account's full path.
What we see in operations
At Accrua, DNFB is read claim by claim, not just as a balance. Agents follow each account from discharge and show how long it has been sitting, what it is worth and which open item is holding it: clinical documentation, OPME (implants and devices), physician fees, authorization or claim closing. The average time from discharge to submission hides the old accounts; the list, sorted by value and age, shows where the cash is stuck.
Each open item goes to whoever can resolve it, with that health plan's filing deadline in view. A high-value account held up by a simple document needs to reach the right person the same day, not at month-end close.
In the assessment, we start from the hospital's claims history to isolate the causes that keep recurring, and that is where we adjust the routine at the source. Through managed operations, Accrua can take over, supplement or rebuild this step with its own billers and auditors.
Where to start
- Take the first snapshot of discharged accounts not yet sent on the last day of the month, and calculate DNFB days with that month's average daily gross revenue.
- Write down the definition: what is included, what is excluded (in-house patients, closed accounts waiting for the batch) and which revenue goes in the denominator.
- Tag each account with a hold reason and name an owner for each reason.
- Build the daily list by value, age and contract submission deadline, and track the weekly trend.
- Use your own series as the baseline: set a reduction target from the first three months measured.