Scaling RCM Through M&A: A CFO Field Guide

Since COVID, M&A has become one of the most powerful levers a healthcare CFO can pull to improve financial performance.

Much of the industry conversation around healthcare M&A centers on top-line impact, including insourcing referrals, diversifying specialty mix, and driving ancillary revenue growth. However, the cost side of M&A has become an increasingly important tool for managing costs as margins tighten. Median hospital operating margins run around 2-3%, and roughly 40% of hospitals still lose money on operations. Outpatient groups and ASCs are no different.

The financial math has only gotten harder over the last decade. Reimbursement has been under pressure for years, and increasingly so since the pandemic. Medicare cut the physician conversion factor five years running, from 2021 through 2025, leaving it down more than 10% since 2020. At the same time, labor inflation has outpaced pricing increases: hospital labor cost per patient rose roughly 37% between 2019 and 2022. When you can’t raise prices and your largest cost keeps climbing, the only way left to protect margin is to operate more efficiently.

The market has responded by accelerating M&A volumes. About 65% of the physicians whose practices were acquired between 2019 and 2023 went to private equity firms. By 2024, fewer than half of U.S. physicians remained in private practice, down from about 60% in 2012, and private equity owned or had invested in roughly 6.5% of them. Specialty groups across dermatology, ophthalmology, orthopedics, and more keep scaling through M&A, even in a higher-rate environment.

One of the hardest parts of a deal to integrate is the RCM team. Get it wrong, and you won’t see it right away, but within months you’ll have ballooning AR backlogs and write-offs. Get it right, and RCM can become a strategic lever for growth and shift from a purely variable cost toward a more fixed one, allowing for margin expansion.

As we’ve talked with CFOs and RCM leaders across our customers and the industry, we’ve heard a thing or two about what good looks like. We’ve put together a field guide on getting it right.

People

Every RCM team is staffed and run differently. A target’s operation could be in-house, co-sourced, outsourced, or a mix of all three, and each comes with its own cost structure and trade-offs:

In-house. You hire and manage RCM team members directly. It gives you the most control. It can also lead to high quality — if your team is fully staffed, trained, and well-managed. However, that can be very hard to pull off, given staffing shortages and high turnover, with positions potentially taking 3-6 months to fill. That, and the cost of in-house staff, makes going purely in-house expensive and risky.

Co-sourcing. You combine a partially in-house team with a third-party partner, to whom you delegate a portion of your claims. It scales up or down with less hiring lead time and carries less turnover risk than your own team. The trade-off is that success is highly dependent on the quality of your partner and their ability to follow your SOPs.

Outsourcing. You hand the full revenue cycle to a vendor, usually on a percentage of collections. It’s the easiest to scale and the most hands-off, and the contingency model loosely ties the vendor’s fees to what it collects. But it often costs as much as an onshore team, you lose visibility into how claims get worked, and vendors tend to cherry-pick the easy claims and leave revenue uncollected.

What good looks like: form a plan before the deal closes. Top-performing groups almost always centralize RCM functions, which makes efficiency gains easier. Centralizing also lets you route work by complexity, payer, dollar amount, and more, so simpler claims can be routed to a co-sourced team and the complex ones to your in-house RCM specialists.

What goes wrong: teams that maintain the status quo avoid a near-term challenge but create a long-term headache. Split teams prevent cost synergies from being realized, claims cannot be routed efficiently, and when the reimbursement environment changes, it becomes difficult to steer the RCM team in one consistent direction. Over time, that shows up as higher cost to collect, more write-offs, and a rising denial rate.

Process

To run a good process, you need good documentation.

One of the biggest financial risks post-close, and one operators rarely plan for, is whether the documentation is saved and centralized. Turnover usually increases after a merger. When staff walk out the door, the knowledge behind enrollment, credentialing, and payer contracts often walks out with them. That delays your ability to centralize processes, take on new providers, or load new payer contracts, and the losses add up.

What good looks like: before you change anything, capture. Map who holds the institutional knowledge: payer contacts, escalation paths, and the workflow logic that rarely gets written down.

Then document the current state: how each entity works, why, and what’s payer-driven versus internally chosen. Even before the deal closes, have finance leadership ask each RCM team to centralize documentation across legal entities, including credentialing, contracting, and SOPs. If it doesn’t exist at the target, have their RCM leadership start a “documentation initiative,” with each team member drafting and centralizing their piece.

Standardize process and expectations before you consolidate. Merging two teams running two different processes doesn’t fix the problem; it just moves it. Identify where work overlaps and what can centralize immediately versus what needs longer-term planning. Then centralize, with clear interim ownership during the transition and your baseline in place so you can see what’s working.

What goes wrong: neither your team nor the target’s team treats the merger as the moment to drive documentation. A few months or years later, after enough turnover, no one has centralized files for the key RCM functions. Denials start creeping up, and the team scrambles to find the data it needs to fix them. The biggest risk is that the individuals who have the tribal knowledge of what an undocumented process looks like – or where any such documentation is – walk out the door with that knowledge.

Technology

Finance and RCM leaders need one thing from the technology: a current, reliable read on how the combined business is performing.

Right after an acquisition, the pre-merger entities usually run different PM systems and analytics platforms. That means data cannot be easily reconciled, and KPI definitions differ.

The goal post-close is aggregated data, with common metric definitions and near-live data updates, ideally every 24 hours. Without it, leadership can’t track the KPIs that matter, like denial rate, days in AR, productivity, and write-offs. In turn, that keeps leadership from making changes when they’re needed.

What good looks like: identify a path to aggregate systems and data post-close. In an ideal state, all entities will be on the same PM system, analytics platform, and more. However, if you need to keep different systems, a data lake pools the data across sources and still gives you one centralized view. Either path is a real lift, so most groups build an internal analytics team or bring in an analytics partner to help with aggregation.

What goes wrong: the data stays siloed, and finance and RCM leaders either have no read on performance or get it late, inconsistently, and only after heavy manual work. That makes trending almost impossible, and it leaves leadership reacting late when the environment shifts.

The Bottom Line

As the pressure on healthcare finance keeps building, with flat reimbursement and rising costs, M&A will stay one of the few levers a CFO can pull to meaningfully change the financial profile of a provider group.

RCM often gets treated as an afterthought in an integration. However, a well-run deal can make RCM a lever for both substantial near-term synergies and long-term scalable operations, while a poorly planned or managed RCM merger can lead to financial risk within 12–18 months. The best CFOs treat RCM as a strategic opportunity in an M&A deal.

If you’d like to compare notes on what we’ve seen with RCM integration across our customers, talk with a CFO in the Amperos network, or see how Amperos’s AI co-sourcing supports a more scalable RCM operation post-close, reach out to me at scott@amperoshealth.com.

Sources

Kaufman Hall, National Hospital Flash Report (2025), reported in HealthLeaders Media, Hospital Financial Performance Gap Widens as Margins Hold Flat; Strata Decision Technology data reported by Advisory Board, The current state of hospital finances (2024).

American Medical Association, Medicare conversion factor, 2020–2025 (chart); Medicare conversion factor history (PDF).

American Medical Association, Medicare physician pay has plummeted since 2001; Medicare updates compared to inflation chart (2025).

Kaufman Hall, National Hospital Flash Report (2022), reported in Fierce Healthcare, Hospitals’ per patient labor spend increased 37% from 2019 to Q1 2022.

American Hospital Association, Setting the Record Straight: Private Equity and Health Insurers Acquire More Physicians than Hospitals (June 2023); U.S. Government Accountability Office, Health Care Consolidation (GAO-25-107450, Sept. 2025).

American Medical Association, Physician Practice Benchmark Survey (2024 data, 2025).