Measure:

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 


Measure:

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 billing prior to submission 


Measure:

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 


Measure:

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 


Measure:

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 


Measure:

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: Average monthly net revenue


Measure:

Aged A/R as a Percent of Billed A/R by Payer Group

Purpose:
Trending indicator of receivable collectability by payer group

Value:
Indicates revenue cycle’s ability to liquidate A/R by payer group

Equation:
N: Billed payer group by aging (0-30, >30, >60, >90, >120 days)
D: Total billed A/R by payer group