The Middlemen: Who Bills on Behalf of Others?
In Medicaid, the billing NPI doesn't always match who performed the service. Some NPIs act as billing intermediaries for dozens or hundreds of other providers. The top intermediary bills on behalf of 5,745+ servicing providers. This is normal for hospitals and health systems — but when a small entity bills for hundreds of providers, it raises questions about pass-through billing and potential fraud.
5,745
Top intermediary count
$42.59B
Through intermediaries
789
Avg providers/intermediary
80
Also on watchlist
NPI: 1699703827
FLAGGEDNPI: 1982757688
FLAGGEDNPI: 1528263910
FLAGGEDWhen a doctor sees a Medicaid patient, the claim filed with the state often comes from a different entity entirely — a hospital, a management company, or a billing organization. The entity that submits the bill is the "billing intermediary," and the providers who actually deliver care are the "servicing providers." This intermediary model is how most of American healthcare billing works.
The Scale of Intermediary Billing
The top 100 billing intermediaries collectively processed $42.59B in Medicaid payments across 455.5M claims. The largest single intermediary bills on behalf of 5,745 servicing providers, while the average intermediary in this list represents 789 providers.
Many of the top intermediaries are exactly what you'd expect: major hospital systems, managed care organizations, and large medical groups. These are legitimate arrangements where an institution files claims on behalf of its employed or affiliated providers. Cleveland Clinic, for example, bills for over 5,000 individual service providers.
When Intermediaries Raise Red Flags
The concerning cases aren't the giant hospital systems. They're the entities that bill for a surprisingly large number of providers while also triggering fraud detection flags. Of the top 100 billing intermediaries, 80 are also on our fraud watchlist — flagged by statistical tests for unusual billing patterns like cost outliers, billing swings, or rapid growth.
78 of these intermediaries were flagged specifically by our code-specific analysis, meaning their per-procedure costs deviate significantly from national benchmarks. When an intermediary bills at rates far above the median across multiple procedure codes — while also representing dozens or hundreds of providers — the overspending is multiplied across every provider they bill for.
Pass-Through Billing Risk
Pass-through billing occurs when an intermediary entity inflates claims before passing payment to the actual service provider. Because the intermediary controls the billing relationship, they can set higher-than-market rates, add unnecessary codes, or bill for services that were never provided — all without the servicing provider's knowledge. The more providers an intermediary bills for, the more opportunities exist for this kind of abuse.
Top 30 Billing Intermediaries
Watchlist Cross-Reference
Of the 100 largest billing intermediaries, 80 also appear on our fraud watchlist. 78 were flagged by the code-specific statistical analysis (cost outliers, billing swings, massive new entrants, or multi-code rate outliers). This doesn't mean these entities are committing fraud — large billing volumes naturally increase the chance of triggering statistical thresholds — but it means their billing patterns warrant closer inspection.
80%
On any watchlist
78
Smart test flags
20
No flags
Important Caveat
Large hospitals and health systems legitimately bill for many providers. A major medical center with thousands of employed physicians will naturally appear as a high-volume billing intermediary. The presence of an entity on this list does not indicate wrongdoing. The concerning cases are smaller, less-established entities that bill for a disproportionately large number of providers relative to their organizational size, especially when combined with other statistical anomalies.
Key Takeaways
- ▸The top billing intermediary in Medicaid bills on behalf of 5,745 servicing providers.
- ▸The top 100 intermediaries control $42.59B in Medicaid payments across 455.5M claims.
- ▸80 of 100 top intermediaries are also on the fraud watchlist, representing entities with statistically unusual billing patterns.
- ▸Most large intermediaries are legitimate hospital systems, but the intermediary model creates opportunities for pass-through billing abuse that is difficult to detect.
Methodology
This analysis identifies billing intermediaries by comparing the billing_npi andservicing_npi fields across 227 million T-MSIS Other Services records (2018–2024). An intermediary is defined as a billing NPI that submits claims on behalf of multiple distinct servicing NPIs. The top 100 are ranked by total payments. Watchlist cross-referencing compares intermediary NPIs against both the code-specific smart watchlist (880 providers) and the legacy expanded watchlist (788 providers).
Source: HHS T-MSIS Other Services File (2018–2024) · 227M records