STEP 1 – Assess your Current Situation

Look for opportunities to analyze your progress. By tracking and comparing key performance indicators, or KPIs, you can identify and address issues with productivity, reimbursement, claims submission, and other processes.

  • Days to final bill—number of days from the time of service until provider generates and submits a claim
  • Days to payment—number of days from time claim is submitted until provider is paid
  • Claims acceptance/rejection rates—percentage of claims accepted/rejected during payer front-end edits (before entering the payer’s adjudication system). To gauge potential this criteria, consider using agings days — 0-30, 31-60, 61-90,91-120, 121+ — from time of service; track by payer and dollar value
  • Claims denial rate—percentage of claims accepted into the payer’s adjudication system that are denied. (Consider keeping separate tallies of authorization and coding denials)
  • Payment amounts—amounts provider receives for specific services (focus on high-volume, resource-intensive services)
  • Reimbursement rate—cents on the dollar provider receives on claim versus the amount billed
  • Coder productivity—number of medical records coded per hour; review by individual coder
  • Volume of coder questions —number of record coders return to clinicians with requests for more documentation to support proper code selection
  • Requests for additional information—number of requests from payers for additional information required to process claims
  • Daily charges/claims—number of charges or claims submitted per day
  • Clearinghouse edits— number and content of edits required by clearinghouses, or claims accepted/rejected by clearinghouse
  • Payer edits—number and reason for edits required by payers
  • Incomplete or missing charges— number of incomplete or missing charges, weekly or monthly
  • Incomplete or missing diagnosis codes—number of incomplete or missing ICD-10 diagnosis codes on orders
  • Use of unspecified codes— volume and frequency of unspecified code use
  • Medical necessity pass rate— rate of acceptance of claims with medical necessity content.

TIP: You don’t have to track all of the KPIs listed below–some might not be practical or relevant for you. But even small steps to identify and resolve issues can get you on the road to higher productivity and more timely claims processing. TIP: Tracking KPIs separately for each payer will assist in isolating the root cause of issues.

STEP 2 – Establish a Baseline

The first step in using KPIs is to establish a baseline, or a point of comparison, for each KPI you’d like to track. For purposes of assessing your progress, you’ll want to compare KPIs from before you started tracking to now. If you’re a provider in a small practice, you might not have routinely used or tracked KPIs in the past, so you may need to start by developing a new baseline with current data. Work with your billing and coding staff to see what data are already available in your systems, reports, and records. Check for data available from outside sources like:

  • Clearinghouses
  • Third-party billers
  • System vendors
  • Consultants

STEP 3 – Track Your KPIs

Once you have established baselines for your KPIs, compare your data from before to put your current KPIs in context. Tracking KPIs can help you detect problems and identify opportunities for improvement. Once you know what the problems are, you can evaluate them to find the root causes and ultimately improve your office’s productivity. Be sure to reevaluate your KPIs on a regular basis as you refine your processes.

TIP: It’s best to compare metrics with past calendar years by month. Seasons can affect statistics, and you will want to take into account local issues (e.g., impact of staff vacations, flu season). Keep this in mind when developing baselines.

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