What "centralized" actually means
Centralized doesn't mean one bank account. It can't, legally, not in how the MSO-PC structure is put together (opens in a new tab). CPOM keeps PCs separate by design.
What it means: one dashboard, one set of policies, one point of control. The money sits in many accounts. The decisions sit in one place.
The hard rule: Money stays in its lane
Patient and payer dollars hit the PC first. Always. The PC then pays the MSO a management fee on a documented schedule. Cash moves down the contractual chain, never sideways.
Break this rule and you've got fee-splitting, which most state medical boards treat as a felony.
The five things to centralize
You can centralize these without touching ownership:
- Sweep rules configured across every PC and the MSO (opens in a new tab)
- A single treasury policy (idle cash thresholds, max single-bank exposure, signing limits)
- One reconciliation feed for ERA 835s, payer EFTs, and check deposits
- Consolidated reporting (cash, AR, deposit insurance coverage)
- Vendor and payroll origination, run from the MSO and charged back to PCs via MSA
What to keep separate
Don't centralize these. Ever.
- PC ownership and signers
- Patient-facing account names and DBAs
- Clinical revenue accounts
- Tax reporting
The PC is its own legal entity. It needs to look and act like one in every audit.
Signs you need this now
You're past DIY when:
- A new PC opening took 4+ weeks
- You had to manually move cash to cover payroll last month
- Two banks called about minimum balances on the same day
- Your CFO can't tell you total deposit coverage in under 30 seconds
- You're carrying $1M+ in idle cash earning under 1%
If two of these hit, you're already paying for the wrong setup.
What it costs to wait
Decentralized treasury isn't free. It costs in three places:
- CFO time: 4-6 hours a week reconciling across portals
- Idle cash drag: $1M sitting at 0.5% leaves $12,500 a year on the table
- Audit risk: messy intercompany flows are the first thing PE diligence flags
A lean treasury team shouldn't be the team that loses its weekends.
The setup that works
A clean centralized treasury looks like this:
- Each PC has its own operating account
- The MSO has its own operating account
- All accounts sit at one bank that supports multi-entity dashboards
- Sweep rules push idle PC cash to interest-bearing or sweep-network accounts
- Reconciling ERA 835s and deposits across every PC (opens in a new tab), with deposits posting to the right entity automatically
- Management fee transfers run on a schedule, papered to the MSA
For Lemma, that looks like $10M FDIC per entity through the IntraFi sweep network, virtual accounts per location for payer EFT routing, and a single dashboard your CFO actually checks on a Tuesday.
Centralized treasury isn't one account. It's one source of truth. Pick a single dashboard across the whole entity structure (opens in a new tab), and the work shrinks from a Friday spreadsheet to a Monday glance.