Claim Key Performance Indicators
The Perry Consulting Group, LLC
We are focused on process improvement to solve daily healthcare organizations' revenue cycle operational challenges.
INSIDE – The?Advantage
__ By Brenda Perry, Executive Director?
November 2022???Issue # 8
The latest; White Paper, News, Views, and Announcements?
Claim Key Performance Indicators
Do you know your organization's first pass rate?
What does the claim's first pass rate mean? The total number of claims resolved on the initial submission (i.e., paid or transferred to patient responsibility) is divided by the total number of claims adjudicated over the same period as a percentage.
A medical claim resolved on the "first pass" should be considered if any claim receives full or partial payment and is transferred to the patient's responsibility on the first initial claim submission.
What is the actual cost of denials?
?Why should this KPI be measured?
Claims not resolved on the initial submission cause significant re-work for the health insurance payer and healthcare providers (doctors/practices, hospitals, healthcare systems, etc.).
Poor inbound claims data (submitted by healthcare providers) is a common reason for claims re-work. Missing claim information (no social security number, missing billing modifier, no plan code, etc.), duplicate claims submissions, and out-of-date submissions (claim not filed past timely can all trigger claims denials, causing significant re-work on both ends (for the insurance company and healthcare provider).
A high amount of re-work in the claims process drives costs, reduces employee productivity, and negatively impacts the customer experience.
How is the KPI calculated?
Two numbers are used to calculate this KPI:
(1) the number of medical insurance claims resolved on the "first pass" and
(2) the total number of medical claims adjudicated by the health insurance company over the same period.
?Characteristics of High-Performing KPIs
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