Billing Employers for Telehealth: PMPM Invoicing and ACH
How PMPM billing in telehealth works: reconcile eligibility files to invoices and collect from employers by ACH without exposing PHI.
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On this page 6 sections
- How PMPM Billing Works in Telehealth Employer Contracts
- Per Member per Month Invoicing vs. Per-Visit and Hybrid Billing
- Reconciling Eligibility Files to Monthly Invoices
- Telehealth Employer ACH Invoicing, Card or Net Terms
- Keeping PHI Out of Invoices and Remittances
- Combining Employer-Paid and Patient-Paid Services
Key takeaways
- Write the definition of "member" into the contract before you quote a rate, because that count drives every invoice.
- Bill from a fixed eligibility snapshot date, and put retroactive adds and terminations on their own dated lines inside an agreed window.
- At a small employer, a single utilization line can identify a coworker, so invoices carry counts and member-level detail moves through a secure channel.
- Employer contract revenue and patient card revenue belong in separate ledgers, and your underwriter should see both described accurately.
PMPM billing in telehealth means an employer or health plan pays you a flat monthly fee for every eligible member, whether or not anyone books a visit. You build each invoice from the employer's eligibility file. Large employer accounts pay that invoice through accounts payable, by ACH, on net terms. The model runs cleanly when two things hold: the member count is right every month, and protected health information (PHI) stays out of the billing trail that lands in an HR or AP inbox.
That second requirement is what separates telehealth from other B2B subscriptions. A software company lists every user on its invoice. You can't.
How PMPM Billing Works in Telehealth Employer Contracts
An employer telehealth contract sets a price for a defined population over a defined period. The employer sends a roster of eligible people and you give them access. The bill follows the roster, not usage.
The definition that decides every invoice is "member." A per-employee-per-month contract (written PEPM) counts only the employee. A per-member-per-month contract counts each covered person, so spouses and dependents add to the bill. At an employer where most staff cover their families, the two counts sit far apart. If your proposal quotes a PMPM rate and the benefits team reads it as PEPM, your first invoice starts a dispute. Write the definition into the contract and name the field in the eligibility file that marks a billable member.
Settle four more terms before the first invoice goes out:
- Snapshot date. The roster on one fixed day of the month sets the bill. The first of the month lines up with benefit coverage dates, which makes it the natural choice.
- Retroactive changes. HR files arrive late. A person terminated in August shows up as terminated in the October file. Agree how many days back an adjustment can reach and whether it posts as a credit or debit on the next invoice.
- Due date and payment method. State when payment is due and which methods you accept. If you charge a late fee, put the amount in the contract.
- Access during nonpayment. Decide what happens to member access when an invoice goes unpaid, and how much notice the employer gets first.
Per Member per Month Invoicing vs. Per-Visit and Hybrid Billing
PMPM is one of three common structures. Each puts usage risk in a different place and creates different invoice work.
| Model | Who carries usage risk | Invoice predictability | Reconciliation work | PHI exposure on invoice |
|---|---|---|---|---|
| PMPM | You (heavy use costs you, light use benefits you) | High for the employer | Eligibility file every month | Low: counts only |
| Per-utilization | Employer | Low, moves with visits | Visit logs every month | Higher: visit lines point toward individuals |
| Hybrid (lower PMPM plus per-visit fee) | Shared | Medium | Both | Set by how you report visits |
Employers like PMPM because it fits a budget line. You like it because revenue arrives in months when engagement is low. Per-utilization appeals to employers who doubt their staff will use the benefit, and it moves the reporting burden onto you: every visit becomes a line that someone in the employer's office has to approve.
Hybrids exist because one service line costs far more to deliver than the rest. Behavioral health sessions are the standard example. If you're still deciding how to package consumer-facing care, our guide to per-visit, membership and bundled telehealth pricing covers the patient-paid side of the same decision.
Reconciling Eligibility Files to Monthly Invoices
An invoice is only as accurate as the roster behind it. A reconciliation routine on a fixed schedule heads off most disputes before they start. The worked example below uses illustrative numbers chosen to show the arithmetic. None of them reflect market rates, so price your own contracts from your costs.
| Illustrative assumption | Value |
|---|---|
| Contract type | Hybrid |
| Access fee | $4.50 per member per month |
| Behavioral health visit fee | $55 per completed visit |
| Snapshot date | The 1st of each month |
| Retroactive window | 60 days |
| Billable members on the October 1 file | 1,240 |
| Terminated effective September 1, already billed for September | 12 |
| Added effective September 1, not billed for September | 8 |
| Behavioral health visits completed in September | 30 |
From those assumptions, the October invoice works out like this:
| Line | Calculation | Amount |
|---|---|---|
| October access fees | 1,240 × $4.50 | $5,580.00 |
| Retro terminations (September) | 12 × $4.50 credit | −$54.00 |
| Retro additions (September) | 8 × $4.50 | $36.00 |
| Clinical visits (September) | 30 × $55.00 | $1,650.00 |
| Total due | $7,212.00 |
Keep every eligibility file you receive, unchanged, with its arrival date. When the next file comes in, compare it to the last one by member ID; names change and IDs shouldn't. Retro adjustments belong on their own lines, labeled with the month they apply to, so the employer's AP clerk can match them to payroll records without emailing you.
Check for anomalies before the invoice goes out. A large drop in headcount from one month to the next means either a layoff or a partial file from HR, and the data alone won't tell you which. Ask. A two-day delay costs less goodwill than a corrected invoice.
Errors creep in at the handoff when eligibility data lives in one system and billing in another. Our article on connecting payments to your telehealth platform or EHR walks through the integration choices.
Telehealth Employer ACH Invoicing, Card or Net Terms
Large employers pay vendors through accounts payable on net terms, and AP teams prefer to push payment by ACH credit on their own schedule. On a large invoice, ACH costs you less than card acceptance. The tradeoff is control over when the money arrives.
- ACH credit (employer pushes). Cheapest for you. Payment arrives on the employer's timeline with a short reference field, so ask AP to put your invoice number in it.
- ACH debit (you pull). Timing is yours, but you need a signed corporate debit authorization. A company that blocks debits on its operating account won't sign one. Your bank or gateway sets the corporate ACH formats and authorization terms you'll use.
- Card. Fits small employers that would rather put a modest monthly bill on a company card. Large employers that pay through AP platforms issuing virtual cards will send those instead. Commercial card acceptance costs more than ACH, so decide in advance whether you take it and whether you'll offset the cost by surcharging where card rules and state law permit.
- Net terms. AP will ask for them. An early-payment discount is one way to speed collection, and our breakdown of 2/10 net 30 versus card fees shows how to price it.
Collections follow different rules here than in consumer subscriptions. A declined patient card gets retries and dunning emails. A late employer has members in the middle of care. Put the notice period and any access suspension in the contract, and talk to counsel before cutting off anyone in active treatment.
Keeping PHI Out of Invoices and Remittances
When a group health plan holds enrollment and utilization data, HIPAA treats that data as PHI. How the rules reach you turns on your role, especially whether you act as a business associate of the employer's group health plan. For privacy purposes, the employer's HR department is not the same thing as its health plan. Confirm your status with a healthcare attorney. This section is general information, not legal advice.
Whatever your exact status, a cautious billing design looks like this:
- Invoices show member counts multiplied by the contracted rate. Nothing that identifies a person belongs there, member IDs included.
- Visit lines use broad categories. "Clinical visits" reveals less than "behavioral health visits."
- Small counts identify people. At an employer with a few dozen staff, "2 behavioral health visits" points at real coworkers. Agree on a minimum reporting threshold with counsel and roll smaller counts into a broader line.
- Member-level reconciliation detail travels through a secure channel to the person the contract names, such as the plan administrator. It never goes to the AP inbox.
- Payment fields carry invoice numbers only. ACH reference fields and card descriptors pass through banks and processors that don't handle them as health data.
Your processor's role matters here too. Read what HIPAA compliance means for your payment processor before you treat any payment channel as safe for clinical detail.
Combining Employer-Paid and Patient-Paid Services
An employer contract covers a defined set of services. Anything outside it, such as prescriptions or specialty consults, falls to the patient. Members who leave the employer also come back as self-pay patients.
Run the two revenue streams separately: employer invoices and ACH receipts in one ledger, patient card payments in another. Then check eligibility at checkout. A member on the current roster sees a covered service at no charge. Anyone else sees the self-pay price and agrees to it before the visit. That check stops the most common double-bill, where the employer pays PMPM for a member and the patient is charged for the same visit.
On the patient side, a stored card with clear consent handles copays and out-of-scope services. Our guide to card on file for copays, self-pay and no-show fees covers the authorization language. Patients also pay with benefit cards, so set up HSA and FSA card acceptance for telehealth visits before the first one arrives.
Underwriting is the last piece. Many processors classify telehealth as high risk, especially when prescriptions or recurring billing are involved, and an application that hides one business line invites a closed account later. Describe what employers pay for under contract and what patients pay for by card. Never route one through the other's account. Our guide to getting a telehealth merchant account approved covers what underwriters review. MannyPay sets up merchant accounts for telehealth and online pharmacy businesses and handles high-risk processing. Its integrations include QuickBooks and Salesforce, so invoice and payment data can sit closer to your CRM and books.
Before your next employer contract renews, pull the last three eligibility files and rebuild each invoice from them. If the totals don't match what you billed, fix the snapshot and retro rules first. When you're ready to review the payment side, request a free quote and a MannyPay specialist will respond within one business day.
This article is for general educational purposes and is not legal, tax or financial advice. Card network rules and state laws change; confirm current requirements for your business.
