Days in Final Billed Not Submitted to Payer (FBNS)

Purpose:
Trending indicator of claims impacted by payer/regulatory edits within claims processing system

Value:
Track the impact of internal/external requirements to clean claim production, which impacts positive cash flow

Equation:
N: Gross Dollars in FBNS
D: Average Daily Gross Revenue 

UB04 (8371) Clean Claim Rate

Purpose:
Trending indicator of claims data as it impacts revenue cycle performance

Value:
Indicates quality of data collected and reported

Equation:
N: number of claims that pass edits requiring no manual intervention
D: total claims accepted into claims scrubber tool for editing prior to submission 

Initial Denial Rate – Zero Pay

Purpose:
Trending indicator of % claims not paid

Value:
Indicates provider’s ability to comply with payer requirements and payer’s ability to accurately pay the claim

Equation:
N: number of zero paid claims denied
D: number of total claims remitted 

Initial Denial Rate – Partial Pay

Purpose:
Trending indicator of % claims partially paid

Value:
Indicates provider’s ability to comply with payer requirements and payer’s ability to accurately pay the claim

Equation:
N: number of partially paid claims denied
D: number of total claims remitted 

Denials Overturned by Appeal

Purpose:
Trending indicator of hospital’s success in managing the appeal process

Value:
Indicates opportunities for payer and provider process improvement and improves cash flow

Equation:
N: number of appealed claims paid
D: total number of claims appealed and finalized or closed 

Denial Write-Offs as a Percent of Net Revenue

Purpose:
Trending indicator of final disposition of lost reimbursement, where all efforts of appeal have been exhausted or provider chooses to write off expected payment amount

Value:
Indicates provider’s ability to comply with payer requirement and payers ability to accurately pay the claim

Equation:
N: net dollars written off as denials
D: Net Patient Services Revenue