What is the difference between in-house and outsourced billing?
With in-house billing, the hospital's own team runs the revenue cycle: claim review and auditing, submission to health plans (called operadoras in Brazil), appeals of denial (a health plan's refusal to pay all or part of a claim) and payment follow-up. With outsourced billing, a specialized company runs part or all of that cycle, and the hospital manages results through KPIs and the contract.
There are also hybrid models, such as outsourcing a single step or sharing operations in co-management; they are covered in the guide Hospital billing outsourcing. This guide focuses on the math: cost, risk and results on each side. In any model, prior authorization and clinical documentation stay with the hospital and drive denials in both scenarios (see Hospital revenue cycle).
The real cost of an in-house team goes beyond payroll
The cost of in-house billing is everything the hospital spends to get a claim right and paid, not just billing salaries. At hospitals that belong to Anahp, staff cost made up 39.03% of total expenses in 2024, up from 36.71% in 2023 [1].
The components that are usually left out:
- Payroll taxes and benefits, plus accruals for vacation pay and the mandatory 13th-month salary.
- Turnover: severance, hiring and the time until a new biller or auditor performs like the previous one.
- Management: coordination, supervision and leadership time spent on billing.
- Clinical auditing: physician and nurse auditors, on staff or contracted.
- Systems and facilities: licenses, claim-scrubbing rules, updates to the TISS standard (the mandatory standard set by ANS, Brazil's National Agency for Supplementary Health, for data exchange with health plans), space and equipment.
- Cost of results: denials that are never appealed, appeals lost to deadlines and extra days until payment.
The last item does not show up on payroll, but it shows up in cash, and it is what makes the comparison fair.
See the components as a table
| Block | In-house billing | Outsourced billing |
|---|---|---|
| Direct cost | Team salaries | Partner fees |
| Direct cost | Payroll taxes, benefits and accruals | Staff who stay at the hospital |
| Direct cost | Turnover: severance, hiring, training | Contract manager |
| Direct cost | Coordination and management | Systems outside the partner's scope |
| Direct cost | Physician and nurse auditors | Transition: assessment and parallel run |
| Direct cost | Systems, TISS updates and facilities | Exit: data return and takeover |
| Cost of results | Accepted denials · financing cost of days to payment · discharged, not billed claims | |
How do you build the cost worksheet?
The worksheet below lays out the annual cost of both models in comparable lines. The fields are blank: values depend on each hospital's size, region and contract. Use the previous 12 months as the baseline. Amounts are in Brazilian reais (BRL).
| Cost line (12 months) | In-house (BRL) | Outsourced (BRL) | Where to find the data |
|---|---|---|---|
| Salaries of the billing, claim review and appeals team | (staff who stay at the hospital) | Payroll | |
| Payroll taxes, benefits and accruals (vacation, 13th salary) | Payroll and accounting | ||
| Physician and nurse auditing | (if outside the partner's scope) | Payroll or audit contracts | |
| Turnover: severance, hiring, training | HR | ||
| Coordination and management | (contract manager) | Payroll and leadership time | |
| Systems: licenses, claim-scrubbing rules, TISS updates | (what the partner does not cover) | IT contracts | |
| Facilities: space, equipment, IT | Accounting allocation | ||
| Partner fees (fixed, variable or mixed) | — | (proposal) | Commercial proposal |
| Transition: assessment, setup, parallel run | — | Proposal and transition plan | |
| Exit: data return and takeover | — | (provision) | Contract |
| Direct cost subtotal | Sum of lines | ||
| Accepted denials (final loss) | (contracted target) | Health plan payment statements | |
| Financing cost of days to payment | (contracted target) | Treasury | |
| Total cost (direct + results) | Sum |
To benchmark salaries against the local market, a Brazilian hospital can use the statistics of RAIS (Relação Anual de Informações Sociais, the annual employer report) and Novo CAGED (Novo Cadastro Geral de Empregados e Desempregados, the monthly hiring and separation register), published free of charge by Brazil's Ministry of Labor and Employment [6].
To estimate the financing cost of days to payment, multiply average daily billings to health plans by the difference in days to payment between the two scenarios, and apply the hospital's borrowing or investment rate. The KPI formula is in the guide Hospital days to payment.
What goes into the cost of outsourcing
The cost of the outsourced model is the partner's fee plus everything that stays with the hospital. Three lines tend to be underestimated.
The staff who stay. The hospital keeps the people who handle authorization, documentation and the relationship with health plans, plus a contract manager.
The transition. In the first months, claims may slow down while the partner learns contracts and systems; see Billing model transition.
The fee model. It defines what the partner will pursue:
| Fee model | Cost predictability | Alignment with hospital cash |
|---|---|---|
| Fixed monthly fee | High | Low: little incentive to improve KPIs |
| Percentage of billed amount | Medium | Low: rewards volume sent, not collected |
| Percentage of collected amount | Medium | High: the partner earns when the hospital gets paid |
| Mixed, with denial and payment-time targets | Medium | High, if the formulas are written into the contract |
In the worksheet, simulate the variable portion on actual collections over the last 12 months.
How do you compare the results of the two models?
Results are compared with the same KPIs, the same formulas and a 12-month baseline. The public benchmarks used here come from the Anahp Observatory:
| KPI | What it shows | Public benchmark |
|---|---|---|
| Initial denial rate | Quality of the claim sent | 15.93% in 2025 (amounts denied and still under negotiation), Anahp hospitals [2]; in 2024, 15.89% of amounts receivable from health plans [1] |
| Accepted denials | Final loss after appeals | 1.72% of gross health plan revenue in 2025, Anahp hospitals [2] |
| Days to payment | (Health plan receivables ÷ health plan revenue) × days in the period; Anahp does not publish its formula | 77.35 days in 2025, against 69.91 in 2024, Anahp hospitals [1][2] |
| Collection rate | Collected ÷ billed to health plans | 88.61% in 2024 (last 5 years), Anahp hospitals [1] |
| Discharge-to-submission time | Billing speed | No public benchmark; use the hospital's own history |
| Discharged, not billed claims | Value of discharged claims not yet sent | No public benchmark; use the hospital's own history |
Full formulas are in the guide Revenue cycle KPIs, and the difference between initial and accepted denials in Initial and final denials.
In the ZG Soluções 2026 Revenue Cycle Panorama (Panorama do Ciclo de Receita), based on the company's own client base and not comparable to the Anahp sample, 67.9% of denied value was attributed to avoidable errors [7]. That process is exactly what you compare between the two models.
The risks of each model, side by side
In-house billing concentrates risk in people; outsourcing concentrates it in the contract and dependence on the partner.
| Risk | In-house | Outsourced |
|---|---|---|
| Key people | Loss of staff who know health plan contracts | Partner reshuffles its team without notice |
| Scale | Hiring and training take time | Depends on the partner's capacity to absorb volume |
| Know-how | Stays at the hospital, but leaves with each departure | Stays with the partner unless the contract requires handover |
| Labor | Liability for the hospital's own staff | Hospital's secondary liability [3] |
| Health data | Hospital is controller and does the processing | Hospital is controller, partner is processor [5] |
| Exit | Not applicable | Requires a data return and takeover plan |
What Law 6,019/1974 says. As amended in 2017, Brazil's outsourcing law allows a company to transfer the performance of any activity, including its core activity, to a contractor with compatible economic capacity [3]. In 2018, Brazil's Supreme Federal Court (STF) upheld outsourcing of both support and core activities (Topic 725) [4]. Four points affect the decision:
- the hospital is secondarily liable for labor obligations during the service period (art. 5-A, § 5) [3];
- a dismissed employee cannot return to serve the hospital as a contractor's employee within 18 months of dismissal (art. 5-D) [3];
- a company whose partners served the hospital as employees or independent workers in the last 18 months cannot be hired, except retirees (art. 5-C) [3];
- when the work is done on the hospital's premises, contractor staff are entitled to the same cafeteria meals, transportation, on-site medical care and training as the hospital's employees (art. 4-C) [3].
In practice, a plan to “move the current team to the partner” may run into arts. 5-C and 5-D and needs legal review.
What the LGPD says. Claims, TISS forms and medical records contain health data, which the LGPD classifies as sensitive [5]. In outsourcing, the hospital usually acts as controller and the partner as processor, handling data under the hospital's instructions [5]. The processor is jointly liable for damages when it breaches the law or the controller's lawful instructions (art. 42, § 1, I) [5]. The law requires records of processing (art. 37), security measures (art. 46) and incident notification by the controller (art. 48) [5]; the contract should state how the partner meets each one. Details are in the guide LGPD in hospital billing.
When the math works for each side
Outsourcing pays off when its total cost, including results, is lower than the total in-house cost. As a formula:
Annual difference = (in-house direct cost + in-house cost of results) − (outsourced direct cost + outsourced cost of results)
If the difference is positive and backed by contract targets, outsourcing tends to pay for itself. If it is negative, the better path may be to strengthen the in-house team with technology or to outsource only the step with the worst KPI. Stable KPIs and an experienced team favor in-house billing; denials and days to payment above the benchmark with no improvement, stalled claims and high turnover favor outsourcing. The business case method is in the guide Revenue cycle ROI.
What we see in operations
Accrua provides this service, so this section describes how the comparison is done here. The assessment starts from the history of claims the hospital has already sent to health plans and shows, claim by claim, where the opportunities are; that picture becomes the baseline before the proposal.
Contracting does not have to be all or nothing. The hospital can contract only the platform, at a fixed fee per processed claim and with no per-user license; the platform plus the operation, with Accrua billers and auditors who have nursing training or a nursing specialization; or both together with receivables advance in the same contract. In the in-house worksheet, this makes it possible to compare step by step instead of one total cost against another.
Where to start
- Add up the in-house direct cost for the last 12 months, line by line, using the worksheet above.
- Measure the baseline for initial and accepted denials, days to payment, discharge-to-submission time and unbilled claims, by health plan.
- Calculate the cost of results: accepted denials plus the financing cost of days to payment.
- Request comparable proposals, with scope, fees tied to collections, targets with formulas, and transition and exit plans.
- Send the decision for legal review, with attention to arts. 5-C and 5-D of Law 6,019/1974 and the LGPD clauses.