• MAP Keys for Hospitals and Health Systems

    The MAP Keys® are strategic key performance indicators (KPIs) that set the standard for revenue cycle excellence in the health care industry. Developed by industry leaders led by HFMA, these industry-standard metrics define the essentials of revenue cycle performance in clear, consistent, and unbiased terms. These strategic keys now apply to acute care hospitals and systems, ambulatory providers, physician organizations, and integrated delivery systems. In other words, there is one set of keys equally applicable to all types of healthcare organizations. There are 29 MAP Keys® (KPIs) for revenue cycle benchmarking divided into 5 major groups. These groups, Patient Access, Pre-Billing, Claims, Account Resolution and Financial Management, reflect the activities represented by the individual keys. An additional unique 6 MAP Keys® have been identified for financial benchmarking within the physician practices only.

    In the interest of total transparency and promotion of the keys as the industry strategic benchmarking standard, details of the individual keys have been expanded to include detailed inclusions and exclusions. Details provided mirror the instructions provided for MAP AppSM, HFMA’s web-based benchmarking resource created by and for the industry to improve revenue cycle performance. These definitions also match the definitions used for the metrics portion of the MAP Award for High Performance in Revenue Cycle application.

    Data used to calculate the MAP Keys® values is derived from a variety of finance and revenue cycle monthly reports. For each key, the most common source for the data has been included in the definitions document. In many cases, the source will be general ledger account(s), which is the preferred source as these numbers are easily audited and confirmed. Where A/R system or other system reports are used, archived copies of the source materials should be retained for audit and confirmation. Most importantly, unless the processing system changes, the same sources must be used each month.

    HFMA recognizes that the implementation of FASB 606 Revenue Recognition rules will impact several MAP Keys® in the reporting of bad debt. Further guidance will be provided as it becomes available.

    Percentage of Patient Schedule Occupied (PA-1)

    Purpose:

    Identifies opportunity to maximize utilization of scheduled availability

    Value:

    Measures available capacity

    Equation and Data Source:

     

    Number of patient slots occupied   =   Scheduling System
    Number of patient slots available         Scheduling System

     

    Points of Clarification:

    “Slots” Are Consistent In Size and Defined By The User

    • Represent available time for patient services

    Excludes:

    • Slots block for non-patient activities

    Number of Patient Slots Occupied

    Includes:

    • Overbooked slots
    • May exceed 100% (overbooking)

    Number of Patient Slots Available

    Includes:

    • Actual number of available slots for use in reporting period

    Pre-Registration Rate (PA-2)

    Purpose:
    Trending indicator that patient access processes are timely and efficient

    Value:
    Indicates revenue cycle efficiency and effectiveness

    Equation & Data Source:

    Number of patient encounters pre-registered  =  Patient Financial System1
       Number of scheduled patient encounters            Patient Financial System

     

    1Data can be drawn from scheduling systems integrated or a bolt-on to the PFS system

     

    Points of Clarification:

    Pre-registered Patient Encounters
    Total number of monthly encounters pre-registered prior to scheduled service. A successful pre-registration is defined as completion of at least all demographic and insurance data fields, and preferably completion of all patient demographic, insurance and financial data fields required for registration as defined by organizational policy. Encounters may be preregistered in-person, over the phone, or electronically.

    Includes:

    • Outpatient encounters; an outpatient account is defined as one encounter; e.g. a recurring account counts as one account and one encounter
    • Inpatient admissions and observation cases (if scheduled in advance)
    • Urgent care appointments, if scheduled (provider option)
    • Canceled pre-registrations
    •  Accounts created from any departmental schedule that qualify for pre-registration per provider policy

    Excludes:

    • Unscheduled pre-admits, walk-in’s, urgent care (if not scheduled) and Emergency encounters

     

    Scheduled Patient Encounters

    Total number of monthly scheduled encounters. A “scheduled encounter” is defined as an encounter scheduled prior to service.

    Includes:

    • Outpatient encounters - an outpatient account is defined as one encounter; e.g. recurring account counts as one account and one encounter
    • Inpatient encounters and observation cases (if scheduled in advance
    • Urgent care appointments, if scheduled (provider option)
    • Canceled pre-registrations

    Excludes:

    • Unscheduled pre-admits, walk-in’s, urgent care (if not scheduled) and Emergency encounters

    Insurance Verification Rate (PA-3)

    Purpose:
    Trending indicator that patient access functions are timely and efficient

    Value:
    Indicates revenue cycle process efficiency and effectiveness

    Equation & Data Source:

    Number of verified encounters        =      Patient Financial System1
    Number of registered encounters            Patient Financial System

     

    1Can be drawn from scheduling systems integrated or bolt-on to the PFS system

     

    Points of Clarification:

    Verified Encounters
    Total of monthly scheduled encounters that have been verified prior to or at time of service AND non-scheduled verified encounters. A successful verification is defined by the individual organization policy.

    Includes:

    • Outpatient encounters - an outpatient account is defined as one encounter; e.g. recurring account counts as one account and one encounter
    • Inpatient encounters
    • Unscheduled book of business, i.e. all walk-in patients, emergency department patients, urgent care patients

     

    Registered Encounters
    Total number of registered encounters reported in same reporting month as numerator. No type of registered encounter is to be excluded from the total - ALL encounters should be included.

    Includes:

    • Outpatient encounters - an outpatient account is defined as one encounter; e.g. recurring account counts as one account and one encounter
    • Inpatient encounters

    Service Authorization Rate- Inpatient and/or Observation (PA-4)

    Purpose:
    Trending indicator that measures what is actually authorized versus the total population that requires authorization

    Value:
    Indicates revenue cycle process efficiency and effectiveness

    Equation & Data Source:

    Number of IP/OBS encounters authorized                        =   Patient Financial System1  
    Number of IP/OBS encounters requiring authorization        Patient Financial System 

     

    1Data may be drawn from scheduling systems integrated or bolted-on to the PFS system

     

    Points of Clarification:

    Authorized Encounters
    Total monthly number of inpatient (IP) and observation (OBS) encounters that have been authorized prior to claim release. “Authorization” is defined as medical necessity approval obtained from the third-party payer for services ordered. A retro-authorization should be counted if completed before claim is released to the payer.

     

    Encounters Requiring Authorization
    Total monthly number of inpatient and observation encounters that require authorization prior to service. “Authorization” is defined as medical necessity approval obtained from the third-party payer for services ordered. The denominator data should be calculated as the numerator (number of authorized encounters) and the number of encounters that were denied due to a lack of authorization.

    Service Authorization Rate- Outpatient Encounter (PA-5)

    Purpose:
    Trending indicator that measures what is actually authorized versus the total population that requires authorization

    Value:
    Indicates revenue cycle process efficiency and effectiveness

    Equation & Data Source:

    Number of outpatient encounters authorized                        =   Patient Financial System1
    Number of outpatient encounters requiring authorization        Patient Financial System

     

    1Data may be drawn from scheduling systems integrated or bolted-on to the PFS system

     

    Point of Clarification:

    Encounters Authorized
    Total monthly number of outpatient (OP) encounters that have been authorized prior to claim release. “Authorization” is defined as medical necessity approval obtained from the third-party payer for services ordered. A retro-authorization should be counted if completed before claim is released to the payer. For the purposes of these keys, authorization and referral approval are considered the same activity.

    Includes:

    • Series accounts, initial encounter or subsequent encounter where a new authorization is required

    Excludes:

    • Inpatient and Observation encounters

     

    Encounters Requiring Authorization
    Total monthly number of outpatient encounters that require authorization prior to service. “Authorization” is defined as medical necessity approval obtained from the third-party payer for services ordered. Data should be calculated as the numerator (number of authorized encounters) plus the number of encounters that were denied due to a lack of authorization.

    Includes:

    • Series accounts, initial encounter or subsequent encounter where a new authorization is required

    Excludes:

    •  Inpatient and Observation encounters

    Conversion Rate of Uninsured Patient to Third-Party Funding Source (PA-6)

    Purpose:
    Trending indicator of qualifying uninsured patients for a third-party funding source

    Value:
    Indicates organization’s ability to successfully secure funding for uninsured patients and improve patient satisfaction

    Equation & Data Source:

    Total uninsured patients
    converted to third-party funding source            =    Accounts Receivable1
    Total uninsured discharges and encounters           Accounts Receivable


    1Includes vendor reports for outsourced accounts

     

    Points of Clarification:

    Uninsured Patients (Discharges and Encounters) Converted to Third-Party Funding Source1,2

    Total patient discharges and encounters approved in the reporting month

    Includes:

    • Inpatients converted at any time
    • Outpatients converted after discharge, including ED, should be counted
    • Conversions of newborns from self-pay to Medicaid because mother has Medicaid
    • Medicaid conversions where provider has received notification from Medicaid agency that coverage is in effect for the specified date of service

    Excludes:

    • Conversions awaiting Medicaid applications (pending approval status)
    1Conversion is counted once valid coverage is verified
    • Must be a third-party funding source; conversions to Charity Care are not counted
    • Third-Party funding sources may include COBRA, Medicaid, worker’s compensation, Third-Party liability (TPL), Supplemental Security Income (SSI), local government programs, etc.
    • Qualifying assumptions:
      • Funding source was identified accurately at time-of-service
      • Funding source identified is new and not a registration error correction
    2All conversions approved in the reporting month are included in the numerator regardless of discharge date

     

    Uninsured Discharges and Encounters

    The total number of uninsured discharges and encounters in the reporting month

    Point-of-Service (POS) Cash Collections (PA-7)

    Purpose:
    Trending indicator of point-of-service collection efforts

    Value:
    Accelerates cash collections and may reduce collection costs

    Equation & Data Source1:

    Patient POS payments              =      Accounts Receivable
    Total self-pay cash collected            Accounts Receivable

     

    1Alternative data source is the general ledger transaction code applied to patient POS cash and the general ledger total for all patient (self-pay) cash collected during the month

     

    Points of Clarification:

    Patient Point-of-Service (POS) Payments

    Point-of-service payments are defined as:

    1. Patient cash (self-pay cash) for a current encounter which is collected prior to, at the time of service, and up to seven days after discharge; and
    2. Patient cash (self-pay cash) for a prior encounter which is collected prior to or at the time of a new service. Note: Payments on prior balances do not count as POS if received any time after the time of a new service; thus, the seven-day window does not apply to prior balances.

    Includes:

    • All posted POS payments, including undistributed payments (debit transactions only)
    • Cash collected on prior encounters, including cash collected on bad debt accounts, at the current pre-service or time-of-service visit
    • Pre-admit dollars captured in the month payment is posted rather than received
    • Combined hospital/physician payments, if included in denominator2

    Excludes:

    • Refunds; cash refunded to the patient should not be considered
    • Routine payment plan payments unless collected at time of service  
    2If reporting hospital data only, physician payments included only for Medicare recognized hospital-based status clinics; if only reporting physician/ambulatory payments, exclude hospital payments for non-physician/non-ambulatory payments. If reporting combined hospital and physician data, report all qualified POS collections.If reporting at the integrated delivery system level, all self-pay cash collected across the system is included.

     

    Self Pay Cash Collected

    Total cash collected for patient responsibility for the reporting month

    Includes:

    • All patient cash collected for the month reported from patient cash account (debit transaction only)
    • All posted self-pay payments, including undistributed payments
    • Bad debt recoveries
    • Loan payments
    • Combined hospital/physician payments, if included in the numerator1
    1If only reporting hospital data, physician payments included only for Medicare recognized hospital-based status clinics; if only reporting physician/ambulatory payments, exclude hospital payments for non-physician/non-ambulatory payments. If reporting combined hospital and physician data, report all qualified POS collections. If reporting at the integrated delivery system level, all self-pay cash collected across the system is included.

    Days in Total Discharged Not Final Billed (DNFB) (PB-1)

    Purpose:
    Trending indicator of claims generation process

    Value:
    Indicates RC performance and can identify performance issues impacting cash flow

    Equation & Data Source:

    Gross dollars in discharged not final billed (DNFB)   =   Unbilled A/R
    Average daily gross patient service revenue                  Income Statement

    Points of Clarification:

    Gross Dollars in Discharged Not Final Billed (DNFB)
    Gross dollars in A/R for all patient accounts (inpatient and outpatient accounts) discharged but not yet final billed for the reporting month. Refers to accounts in suspense (within bill hold days) and pending final billed status in the patient accounting system.

     

    This is a snapshot at month-end.

    Includes:

    • Recurring accounts (i.e. interim bills) as long as they have been discharged but not final billed
    • Accounts discharged and held during a system “suspense period”
    • Ambulatory services charged but not final billed (held in system suspense)

    Excludes:

    • In-house accounts
    • Accounts in FBNS (Final Billed Not Submitted to Payer)

     

    Average Daily Gross Patient Service Revenue
    Monthly gross patient service revenue divided by number of days in the reporting month. This is a single month daily average, not a three-month rolling average.

    Days in Final Billed Not Submitted to Payer (FBNS) (PB-2)

    Purpose:
    Trending indicator of claims impacted by payer/regulatory edits within claims processing tool (claims scrubber tool)

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

    Equation & Data Source:

    Gross dollars in FBNS                                              =    Claims Processing Tool
    Average daily gross patient service revenue              Income Statement 

    Points of Clarification:

    Gross Dollars In Final Bill Not Submitted To Payer (FBNS)
    Gross dollars from initial 837 claims held by edits in claims processing tool that have not been sent to payer. This is a snapshot at month-end.

    Includes:

    • Initial claims only1
    • All 837 claims
    • Claims rejected during submission process by payer (not denied)

    Excludes:

    • In-house accounts
    • Accounts in DNFB (Discharged Not Final Billed); see DNFB Key for definition
    • Rebills and late charge bills (based on bill type codes)

     

    1Initial claims are defined as claims never released to the primary payer for adjudication and payment

     

    Average Daily Gross Patient Service Revenue
    Monthly gross patient service revenue divided by number of days in the reporting month. This is a single month daily average, not a three-month rolling average.

    Days in Total Discharged Not Submitted to Payer (DNSP) (PB-3)

    Purpose:
    Trending indicator of claims generation and submission process

    Value:
    Indicates revenue cycle performance and can identify performance issues impacting cash flow

    Equation & Data Source:

    Gross dollars in DNFB + gross dollars in FBNS   =   KPI PB1 + KPI PB2
    Average daily gross patient service revenue             Income Statement

     

    PB-4 Applicability: PB-4 is not included in this numerator

     

    Points of Clarification:

    Gross Dollars In DNFB + Gross Dollars In FBNS
    Automatically combines DNFB dollars from DNFB (PB-1) and FBNS dollars from FBNS (PB-2) to calculate the total dollars in claims discharged but not submitted to the payer

    Average Daily Gross Patient Service Revenue
    Monthly gross patient service revenue divided by number of days in the reporting month. This is a single month daily average, not a three-month rolling average.

    Total Charge Lag Days (PB-4)

    Purpose:

    Trending indicator of charge capture workflow efficiency

    Value:

    Impacts cash flow

    Equation and Data Source:

    Σ days from revenue recognition (posting date)
    less date of service date (by Charge/CPT code)   =   Patient Financial System
          Σ Count of Chargte/CPT codes billed                        Patient Financial System

     

    Points of Clarification:

    Restricted Use: This key is not to be added to data from accounts, i.e., hospital, physician, ambulatory, and/or post-acute that are included in the data reported in PB-1 and PB-2. If physician, ambulatory and/or post-acute accounts are not included in PB-1 and PB-2, this key may be used for those accounts only as a timeliness proxy indicator of charge posting timeliness.

     

    Sum of Days From Revenue Recognition Date Less Date of Service

    The number of days between the date of service and the date of revenue recognition (posting) for each charge code on the claim. This is also known as the elapsed days between revenue posting date and service date. This is not a total of the charges but rather a count of days.

     

    Sum of the Count: Charge Codes/CPT Billed

    This is a count of the number of charge codes billed, not a summation of dollars billed

    Clean Claim Rate (CL-1)

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

    Value:
    Indicates quality of data collected and reported

    Equation & Data Source

    Number of claims that pass edits requiring no manual intervention   =   Claims Processing Tool
    Number of claims accepted into claims processing tool for billing            Claims Processing Tool

    Points of Clarification:

    Claims That Pass Edits Requiring No Manual Intervention 
    Aggregate daily total of claims in the claims processing tool requiring no manual intervention for reporting month

    Includes:

    • Primary, secondary, and tertiary claims – all applicable 837 claim types

    Excludes:

    • Claims “warned” because intervention is required
    • Claims directly submitted to a third-party payer, thereby bypassing the claim edits
    • Claims “warned” in processing tool for print and hardcopy submission

     

    Claims Accepted Into Claims Processing Tool For Billing Prior To Submission
    Aggregate daily total of claims in the claims processing tool downloaded for reporting month

    Includes:

    • Primary, secondary and tertiary claims
    • Claims “warned” because intervention other than printing is required

    Excludes:

    •  Claims not accepted into the claims processing tool, including direct submissions to third-party payers
    • Claims “warned” in processing tool for print and hardcopy submission should be removed

     

    Late Charges as Percentage of Total Charges (CL-2)

    Purpose:
    Measure of revenue capture efficiency

    Value:
    Helps identify opportunities to improve revenue capture, reduce unnecessary cost, and accelerate cash flow

    Equation & Data Source:

    Gross charges with post date >3 days from service date   =   Patient Financial System
                                  Total gross charges                                             Patient Financial System

    Points of Clarification:

    Gross Charges With Post Date >3 Days From Service Date
    Absolute value of debit and credit charges at transaction level of detail with a post date greater than 3 days from the service date

    1. Absolute value of late debits + absolute value of late credits = total late charges; total late charges are not “net” of late charge credits; in other words, credits are not subtracted from debits
    2. Posting window is service date + 3 days; in other words, if post date minus service date is greater than 3 days, then it is a late charge; late charges begin on the 4th day after service date. “Service Date” is defined as the date a specific service is performed, not the account date or discharge date.
    3. Charges posted within the month
    4. Excludes charges reclassified based on a change in the assigned patient type.

     

    Total Gross Charges
    Total gross patient charges for the reporting month

    Aged A/R as a Percentage of Total Billed A/R (AR-1)

    Purpose:
    Trending indicator of receivable aging and collectability

    Value:
    Indicates revenue cycle effectiveness at liquidating A/R

    Equation & Data Source:

    0-30, 31-60, 61-90, 91-120, > 120 days   =   Aged Trial Balance
                      Total billed A/R                                   Aged Trial Balance

    Points of Clarification:

    Billed A/R By Aging Category
    (0-30, 31-60, 61-90, 91-120, > 120 days)

    Total billed A/R1 amount for all payers in each aging category, aged from discharge date (inpatient) or date of service (outpatient/ambulatory/physicians). Aging buckets are mutually exclusive categories and must sum to 100%.

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    •  Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts; see DNFB Key for definition
    • In-house accounts
    • In-house interim-billed accounts
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)
    1Billed A/R at the account level; does not include In-house or DNFB
    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

    Total Billed A/R
    Total billed A/R1 amount for all payers in reporting month, aged from discharge date.

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts; see DNFB Key for definition
    • In-house accounts
    • In-house, interim-billed accounts
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)
    1Billed A/R at the account level; does not include In-house or DNFB
    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

    Aged A/R as a Percentage of Billed A/R by Payer Group (AR-2)

    Purpose: 
    Trending indicator of receivable collectability by payer group

    Value:
    Indicates revenue cycle effectiveness at liquidating A/R by payer group

    Equation & Data Source:

    Billed A ⁄ R by payer group by aging category   =   Aged Trial Balance
                Total billed A/R by payer group                      Aged Trial Balance


    Points of Clarification:

    Billed A/R By Payer Group By Aging Category

    Total billed A/R1 amount by payer in each aging category, aged from discharge date (hospitals) or date of service (ambulatory/physicians/post acute). Aging buckets are mutually exclusive categories and must sum to 100%.

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts ; see DNFB Key for definition
    • In-house accounts
    • In-house interim-billed accounts not billed at month-end
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)
    1Billed A/R at the account level; does not include In-house or DNFB
    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

    Total Billed A/R By Payer Group
    Total billed A/R1 amount by payer in reporting month, aged from discharge date (hospitals) or date of service (hospitals/ambulatory/physicians).

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts; see DNFB Key for definition
    • In-house accounts
    • In-house, interim-billed accounts not billed at month-end
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)
    1Billed A/R at the account level; does not include In-house or DNFB
    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

    Aged A/R as a Percentage of Total A/R (AR-3)

    Purpose:
    Trending indicator of receivable aging and collectability

    Value:
    Indicates revenue cycle effectiveness at liquidating A/R

    Equation & Data Source:

    Unbilled, 0-30, 31-60, 61-90, 91-120, > 121 days      =      Aged Trial Balance
                                           Total A/R                                                Aged Trial Balance

     

    Points of Clarification:
    Unbilled and Billed A/R By Aging Category

    (Unbilled, 0-30, 31-60, 61-90, 91-120, > 121 days) 
    Total A/R1 amount for all payers in each aging category, i.e., in-house and DNFB, and billed A/R by discharge date. Aging buckets are mutually exclusive categories and must sum to 100%.

     

    Unbilled is defined as revenue in-house and discharged but not final billed. It also includes final billed not submitted to payer if not automatically included in the 0-30 day aging category.

    Includes:

    • Only active debit balance accounts; “active accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active credit balance accounts; these should be removed from the data2
    1Includes in-house and DNFB, billed A/R in standard aging categories
    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

    Total A/R
    Total A/R amount for all payers in reporting month

    Includes:

    • Only active debit balance accounts; “active accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active credit balance accounts; these should be removed from the data

    Aged A/R as a Percentage of A/R by Payer Group (AR-4)

    Purpose:
    Trending indicator of receivable collectability by payer group

    Value: 
    Indicates revenue cycle effectiveness at liquidating A/R by payer group

    Equation & Data Source:

    Unbilled, 0-30, 31-60, 61-90, 91-120, > 120 days by Payer  =   Aged Trial Balance
                                                    Total A/R                                                 Aged Trial Balance

    Points of Clarification:

    Unbilled and Billed A/R By Payer Group By Aging Category

    Total A/R1 amount for all payers in each aging category, i.e., in-house and DNFB, billed A/R by discharge date. Aging buckets are mutually exclusive categories and must sum to 100%.

     

    Unbilled is defined as revenue in-house and discharged but not final billed. It also includes final billed not submitted to payer if not automatically included in the 0-30 day aging category.

    Includes:

    • Only active debit balance accounts; “active accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active credit balance accounts; these should be removed from the data2
    1Includes in-house and DNFB, billed A/R in standard again categories
    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

    Billed A/R By Payer Group

    Total A/R amount by payer in reporting month, in-house and DNFB, billed A/R aged by discharge date. Aging buckets are mutually exclusive categories and must sum to 100%.

    Includes:

    • Only active debit balance accounts; “active accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active credit balance accounts; these should be removed from the data

    Remittance Denial Rate (AR-5)

    Purpose:
    Trending indicator of % of claims denied

    Value:
    Indicates provider’s ability to comply with payer requirements and payers’ ability to accurately pay the claim; efficiency and quality indicator

    Equation & Data Source:

    Total number of claims denied      =   Accounts Receivable1
    Total number of claims remitted        835 Files and/or Paper Remittance
    1Billed A/R = electronic 835/paper source as remit

     

    Points of Clarification:

    Number of Claims Denied
    Total claims adjudicated monthly at claim level. Denials are defined as “actionable denials” - those denials that may be addressed and corrected within the organization and may result in appropriate reimbursement.

    Includes:

    • Only payments containing a denial code on the remittance advice1
    • Both initial claim denials and subsequent appeal denials
    • Zero payment and partial payment accounts containing a denial indicator

    Excludes:

    • Denials for plan excluded (non-covered) services
    • Denials for patient responsibility
    • RAC recoupments
    • Denials for duplicate claims
    • Shadow/encounter claims
    1HFMA may provide generic CARC and group code mappings; providers should verify applicability by payer; transaction codes may be used to capture individual actionable denials for reporting and work queue purposes. However, the volume reported is defined as number of claims, not number of line items denied.

     

    Number of Claims Remitted

    Total claims remitted monthly. Remitted claims can be received electronically or through paper process. If 835 data is not accessible, use total insurance payment volumes at the account level. Any report that counts line item detail should not be used; this metric uses the claim as the correct unit to count.

    Denial Write-Offs as a Percentage of Net Patient Service Revenue (AR-6)

    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 payer’s ability to accurately pay the claim

    Equation & Data Source:

    Net dollars written off as denials                              =   Patient Financial System
    Average monthly net patient service revenue            Income Statement

     

    Points of Clarification:
    Net Dollars Written Off As Denials
    Total dollars written off as a denial in the reporting month, net of recoveries

    Includes:

    • Denied RAC dollars resulting from lost appeals or choosing not to appeal
    • Dollars must be stated at net

     

    Average Monthly Net Patient Service Revenue
    Most recent three-month average1 of total net patient service revenue. Net patient service revenue is defined as gross patient service revenue minus contractual allowances, minus charity care provision, then minus the provision for doubtful accounts. Note: Gross patient service revenue does not appear on the audited income statement.

    Includes:

    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare IME paid on a MS-DRG basis

    Excludes:

    • Medicaid Disproportionate Share Hospital (DSH)
    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Any state or county subsidy, ambulance services, tax and match type assessments, retail pharmacy, post-acute services and physician practice/clinic unless the clinic is a Medicare recognized provider-based status clinic. Note: this exclusion does NOT apply to Integrated Delivery Systems
    • Capitation and/or premium revenue related to value or risk based payer contracts
    1Most recent three months is defined as the month most recently ended plus the two months immediately before the most recently ended month

    Bad Debt (AR-7)

    Purpose:
    Trending indicator of the effectiveness of collection efforts and financial counseling

    Value:
    Indicates organization’s ability to collect accounts and identify payer sources for those who cannot meet financial obligations

    Equation & Data Source:

    Bad Debt                                         =    Income Statement1
    Gross patient service revenue          Income Statement

     

    1Alternative source is the general ledger transaction(s) as recorded in the allowance/ provision for doubtful accounts G/L account(s

     

    Points of Clarification:

    Bad Debt

    Total bad debt deduction as shown on the income statement for the reporting month. This is not the amount written off from A/R. Also called “Provision for Uncollectible Accounts”, or “Provision for Bad Debt.”

     

    Gross Patient Service Revenue

    Total gross patient service revenue for the reporting month 

    Charity Care (AR-8)

    Purpose:

    Trending indicator of the administration of the provider’s financial assistance policy

    Value:

    Indicates services provided under the provider’s financial assistance policy

    Equation and Data Source:

              Charity care1                       =    Income Statement
    Gross patient service revenue          Income Statement

     

    Points of Clarification:

    Charity Care

    Total charity care1 as shown on income statement for the reporting month, not the amount written off from A/R


    Gross Patient Service Revenue

    Total gross patient service revenue for the reporting month

     

    1Maybe shown only as a footnote to the financial reports; does not include community benefit amounts

    Net Days in Credit Balance (AR-9)

    Purpose:

    Trending indicator to accurately report account values, ensure compliance with regulatory requirements, and monitor overall payment system effectiveness

    Value:

    Indicates process failure in timely cash posting, incorrect posting or incorrect payment

    Equation and Data Source:

                Dollars in credit balance                       =    Aged Trial Balance
    Average daily net patient service revenue        Income Statement

     

    Points of Clarification:
    Dollars In Credit Balance
    Any patient account with a credit balance at the account level, reported as the absolute value of the credit balance

    Excludes:

    • Pre-service deposits
    • In-house (not discharged) accounts
    • Undistributed cash clearing accounts

     

    Average Daily Net Patient Service Revenue
    Most recent three-month daily average1 of total net patient service revenue. Net patient service revenue is defined as gross patient service revenue minus contractual allowances, minus charity care provision, then minus the provision for doubtful accounts. Note: Gross patient service revenue does not appear on the audited income statement.

    Includes:

    • Medicare Disproportionate Share Hospital (DSH)
    • Medicare IME paid on a MS-DRG basis

    Excludes:

    • Medicaid Disproportionate Share Program (DSH)
    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Any state or county subsidy, ambulance services, tax and match type assessments, retail pharmacy, post-acute services and physician practice/clinic unless the clinic is a Medicare recognized provider-based status clinic. Note: this exclusion does NOT apply to Integrated Delivery Systems
    • Capitation and/or premium revenue related to value or risk based payer contracts
    1Most recent three months is defined as the number of days in the three months including the last month being reported. For example, data submitted for the three months ending June 30 includes April (30 days), May (31 days) and June (30 days) for a total of 91 days used to calculate the average daily net patient service revenue.
    See MAP Key FM-1 for additional definition and footnote information

    Net Days in Accounts Receivable (A/R) (FM-1)

    Purpose:
    Trending indicator of overall A/R performance

    Value:
    Indicates revenue cycle (RC) efficiency

    Equation & Data Source:

    Net A/R                                                                 =   Balance Sheet
    Average daily net patient service revenue      Income Statement 

    Points of Clarification:

    Net A/R

    Net A/R is the net patient receivable on the balance sheet. It is net of credit balances, allowances for uncollectible accounts, discounts for charity care, and contractual allowances for third-party payers.

    Includes:

    • A/R receivables outsourced to third-party company but not classified as bad debt
    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare Indirect Medical Education (IME) paid on a MS-DRG account by account basis
    • A/R related to patient specific third-party settlements; a "patient specific settlement" is a payment applied to an individual patient account
    • CAH payments and settlements

    Excludes:

    • A/R related to non-patient specific third-party settlements; a “non-patient specific settlement” is payment that is not applied directly to a patient account; it may appear as a separate, lump sum payment unrelated to a specific account. Examples include Medicaid Disproportionate Share Hospital (DSH), CRNA, and Direct Graduate Medical Education (DGME) payments as well as cost report settlements.
    • Non-patient A/R
    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Any state or county subsidy, ambulance services, tax and match type assessments, retail pharmacy, post-acute services and physician practice/clinic unless the clinic is a Medicare recognized provider-based status clinic. Note: this exclusion does NOT apply to Integrated Delivery Systems.
    • Capitation and/or premium revenue related to value or risk based payer contracts

     

    Average Daily Net Patient Service Revenue
    Most recent three-month daily average of total net patient service revenue. Net patient service revenue is defined as gross patient service revenue minus contractual allowances, minus charity care provision, then minus the provision for doubtful accounts. Note: Gross patient service revenue does not appear on the audited income statement.

    Most recent three months is defined as the number of days in the three months including the last month being reported. For example, data submitted for the three months ending June 30 includes April (30 days), May (31 days) and June (30 days) for a total of 91 days used to calculate the average daily net patient service revenue.

    Includes:

    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare IME paid on a MS-DRG basis

    Excludes:

    • Medicaid Disproportionate Share Hospital (DSH)
    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Any state or county subsidy, ambulance services, tax and match type assessments, retail pharmacy, post-acute services and physician practice/clinic unless the clinic is a Medicare recognized provider-based status clinic. Note: this exclusion does NOT apply to Integrated Delivery Systems
    • Capitation and/or premium revenue related to value or risk based payer contracts

     

    Example Income Statement: 
    Net patient service revenue before provision for doubtful accounts1$500,000 
    Less Provision for doubtful accounts $10,000 
    Net Patient Service Revenue $490,000 

     

    1Net patient service revenue before provision for doubtful accounts is gross patient service revenue minus contractual allowances, minus charity care provision; under current accounting guidance, gross revenue does not appear in the financial statements

    Cash Collection as a Percentage of Net Patient Service Revenue (FM-2)

    Purpose:
    Trending indicator of revenue cycle ability to convert net patient services revenue to cash

    Value:
    Indicates fiscal integrity/financial health of the organization

    Equation & Data Source:

    Total patient service cash collected                          =   General Ledger
    Average monthly net patient service revenue           Income Statement

    Points of Clarification:

    Total Patient Service Cash Collected
    Total patient service cash collected for the reporting month, net of refunds.

    Includes:

    • All patient service payments posted to patient accounts, including undistributed payments
    • Bad debt recoveries
    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare Indirect Medical Education (IME) payments

    Excludes:

    • Non-patient-related settlements/payments; examples: capitation, Safety Net, Direct Graduate Medical Education (DGME), Medicare Pass through, Medicaid DSH
    • Non-patient Cash; examples: retail pharmacy, gift store, cafeteria
    • Ambulance, post-acute care services, and physician practices/clinics unless Medicare recognized provider-based status clinics. Note: this exclusion does NOT apply to Integrated Delivery Systems.

     

    Average Monthly Net Patient Service Revenue
    Most recent three-month average of total net patient service revenue.1 Net patient service revenue is defined as gross patient service revenue minus contractual allowances, minus charity care provision, then minus the provision for doubtful accounts. Note: Gross patient service revenue does not appear on the audited income statement.

    Includes:

    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare IME paid on a MS-DRG basis

    Excludes:

    • Medicaid Disproportionate Share Hospital (DSH)
    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Any state or county subsidy, ambulance services, tax and match type assessments, retail pharmacy, post-acute services and physician practice/clinic unless the clinic is a Medicare recognized provider-based status clinic. Note: this exclusion does NOT apply to Integrated Delivery Systems
    • Capitation and/or premium revenue related to value or risk based payer contracts
    1Most recent three months is defined as the month most recently ended plus the two months immediately before the most recently ended month

    Uninsured Discount (FM-3)

    Purpose:
    Trending indicator of amounts not expected to be paid by uninsured patients

    Value:
    Indicates the portion of the self-pay gross revenue not included in cash, charity, or bad debt metrics

    Equation & Data Source:

    Uninsured discounts (prior to charity care and bad debt)   =   Accounts Receivable
    Gross patient service revenue                                                        Income Statement

    Points of Clarification:

    Uninsured Discounts

    Total patient revenue reported at month-end as “Uninsured Discount” prior to transfer to bad debt, as shown on income statement for the reporting month. If patient later qualifies for Charity Care, this discount is reversed and the Charity Care discount is applied, which should reflect a reduction in this amount in the month reversed.

    Includes:

    • Any account registered without insurance, except where exclusions apply

    Excludes:

    • Charity Care
    • Bad Debt
    • Discounts to self-pay balance after insurance payment
    • Prompt-pay discounts

     

    Gross Patient Service Revenue

    Total gross patient service revenue for the reporting month.

    Uncompensated Care (FM-4)

    Purpose:
    Trending indicator of total amounts not collected from patients related to self-pay discounts, charity care, and bad debt combined

    Value:
    Indicates the portion of the self-pay gross revenue not included in cash, charity, or bad debt metrics

    Equation & Data Source:

    Uncompensated care                =   KPI AR5 + AR6 + FM3
    Gross patient service revenue        Income Statement

    Points of Clarification:

    Uncompensated Care
    Sum of uninsured discounts, charity care, and bad debt for the reporting month.


    Gross Patient Service Revenue
    Total gross patient service revenue for the reporting month.

    Case Mix Index (FM-5)

    Purpose:
    Trending indicator of patient acuity, clinical documentation and coding

    Value:
    Supports appropriate reimbursement for services performed and accurate clinical reporting

    Equation & Data Source:

    Sum of relative weights for inpatients                  =   Encoder-Decision Support
    Number of discharged inpatients in the month       Encoder-Decision Support

    Points of Clarification:

    Sum of Relative Weights for Inpatients
    Sum of Medicare MS-DRG weights universally applied to all discharged inpatients for the reporting month1. Only applicable to hospitals and hospital systems, including hospitals and hospital systems within an integrated delivery system.

    Excludes:

    • Normal newborns; for hospitals with a NICU, normal newborns will have a revenue code of UB 0170 or UB 0171 - only these should be excluded
    • Medicare exempt units; A “Medicare exempt unit” is a unit that does not qualify for Medicare reimbursement, under IPPS, for example, Medicare IPPS exempt psychiatric specialty units. Note: this exclusion does NOT apply to Integrated Delivery Systems unless no MS-DRG assignment is processed.
    1Data for the reporting month may be updated until all included cased have been coded and assigned to a MS-DRG

     

    Discharged Inpatients in the Month

    Discharged inpatient count for the reporting month, excluding normal newborns. Only applicable to hospitals and hospital systems, including hospitals and hospital systems within an integrated delivery system.

    Excludes:

    • Normal newborns; for hospitals with a NICU, normal newborns will have a revenue code of UB 0170 or UB 0171 - only these should be excluded
    • Medicare exempt units; A “Medicare exempt unit” is a unit that does not qualify for Medicare reimbursement, under IPPS, for example, Medicare IPPS exempt psychiatric specialty units. Note: this exclusion does NOT apply to Integrated Delivery Systems unless no MS-DRG assignment is processed.

    Cost to Collect (FM-6)

    Purpose:
    Trending indicator of operational performance

    Value:
    Indicates the efficiency and productivity of revenue cycle process

    Equation & Data Source:

    Total revenue cycle cost                      =   Income Statement
    Total patient service cash collected        Balance Sheet

    Points of Clarification:

    Revenue Cycle Cost

    The following Revenue Cycle Costs should be reported with their respective functional area’s costs as applicable: salaries and fringe benefits, subscription fees, outsourced arrangements, purchased services, software maintenance fees, bolt-on application costs and their associated support staff, IT operational expenses related to the revenue cycle, record storage, contingency fees, and transaction fees.

    Includes:

    • Patient Access Expense: eligibility and insurance verification, cashiers, centralized scheduling, pre-registration, admissions/registration, authorization/pre-certification, financial clearance, Medicaid eligibility, and financial counseling
    • Patient Accounting Expense: billing, collections, denials, customer service, subscription fees, collection agency fees, Charge Description Master/revenue integrity, cash application, payment variances, and all related expenses associated with these functions
    • HIM Expense: transcription, coding, Clinical Documentation Improvement (CDI), chart completion, imaging, and all related expenses associated with these functions regardless of reporting structure

    Excludes:

    • IT “Hard” costs: capitalized costs such as hardware, licensing fees, core HIS and PAS, servers, and any FTE that supports these
    • Lease/Rent expenses
    • Physical space costs: utilities, maintenance, depreciation
    • Scheduling if performed in the service departments by service department personnel

     

    Patient Service Cash Collected

    Total patient service cash collected for the reporting month, net of refunds

    Includes:

    • All patient service payments (insurance and patient pay) posted to patient accounts, including undistributed payments
    • Bad debt recoveries
    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare Indirect Medical Education (IME) payments

    Excludes:

    • Patient-related settlements/payments; examples: capitation, Safety Net, Direct Graduate Medical Education (DGME), Medicare Pass Through, Medicaid DSH
    • Non-patient cash; examples: retail pharmacy, gift store, cafeteria
    • Patient cash collected for ambulance, post-acute care services, and physician practices/clinics unless Medicare recognized provider-based status clinics.Note: this exclusion does NOT apply to Integrated Delivery Systems.

    Cost to Collect by Functional Area (FM-7)

    Purpose:
    Trending indicator of operational performance by functional area as reported in KPI FM-6

    Value:
    Indicates the efficiency and productivity of revenue cycle process by functional area

    Equation & Data Source:

    Total x (x = each functional area) cost   =   Income Statement
    Total patient service cash collected                  Balance Sheet

    Points of Clarification:

    Total x (x=each functional area) Cost

    Breakdown of revenue cycle cost based on functional area. Functional areas include patient access, patient accounting, and HIM. The following Revenue Cycle Costs should be reported with their respective functional area’s costs as applicable: salaries and fringe benefits, subscription fees, outsourced arrangements, purchased services, software maintenance fees, bolt-on application costs and their associated support staff, IT operational expenses related to the revenue cycle, record storage, contingency fees, and transaction fees.

    Includes:

    • Patient Access Expense: eligibility and insurance verification, cashiers, central scheduling, pre-registration, admissions/registration, authorization/pre-certification, financial clearance, Medicaid eligibility, and financial counseling
    • Patient Accounting Expense: billing, collection denials, customer service, subscription fees, collection agency fees, CDM/revenue integrity, cash application, payment variances, and all related expenses associated with these functions
    • HIM Expense: transcription, coding, Clinical Documentation Improvement (CDI), chart completion, imaging, and all related expenses associated with these functions regardless of reporting structure

    Excludes:

    • IT “Hard” costs: capitalized costs such as hardware, licensing fees, core HIS and PAS, servers, and any FTE that supports these
    • Lease/Rent expenses
    • Physical space costs: utilities, maintenance, depreciation
    • Scheduling if performed in the service departments by service department personnel

     

    Patient Service Cash Collected

    Total patient service cash collected for the reporting month, net of refunds.

    Includes:

    • All Patient Service payments (insurance and patient pay) posted to patient accounts, including undistributed payments
    • Bad debt recoveries
    • Medicare Disproportionate Share Hospital (DSH) payments
    • Medicare Indirect Medical Education (IME) Payments

    Excludes:

    • Patient-related settlements/payments; examples: capitation, Safety Net, Direct Graduate Medical Education (DGME), Medicare Pass-Through, Medicaid DSH
    • Non-patient Cash; examples: retail pharmacy, gift store, cafeteria
    • Ambulance, post-acute care services, and physician practices/clinics unless Medicare recognized provider-based status clinics. Note: this exclusion does NOT apply to Integrated Delivery Systems
  • MAP Award Winner Statistical Data

    Learn more about HFMA’s standard and recommended benchmarks by reviewing statistical data from the MAP Awards winners.

    See the details.

  • MAP Keys for Physician Practice Management

    The HFMA MAP Keys® Task Force has completed the development of a conforming set of 29 key performance metrics for strategic revenue cycle benchmarking, applicable to all provider types. For MAP App subscribers to the Physician Module, the first 8 MAP Keys to follow are a duplicate of the consolidated list. In addition, the 6 MAP Keys in the “Physician Financial Management” section are to be used exclusively for physician practice data reporting.

    Note: HFMA recognizes that the implementation of FASB 606 Revenue Recognition rules will impact several MAP Keys in the reporting of bad debt. Further guidance will be provided as it becomes available.

    The below are the definitions for onboarding the PPM Keys. Refer to demographic options within the application for assignment of various comparison criteria.

    Percentage of Patient Schedule Occupied (PPM: PA-1)

    Purpose:
    Identifies opportunity to maximize utilization of scheduled availability

    Value:
    Measures available capacity

    Equation and Data Source:

    Number of patient slots occupied      =       Scheduling System
    Number of patient slots available                  Scheduling System

     

    Points of Clarification:

    "Slots" Are Consistent In Size and Defined By the User

    The slots reported should represent time attributed as available for professional and ancillary services provided to patients. Schedule availability blocked for non-patient care reasons should not be counted.

     

    Number of Patient Slots Occupied

    Includes:

    The numerator includes overbooked slots, which may increase the percentage to greater than 100%, which may be accurate. Slots designated as cancellations and no shows are included in the “occupied” count unless these designations have been removed and the slot is utilized for a scheduled service.

     

    Number of Patient Slots Available

    Includes:

    The actual number of slots available for use during the period being reported.

    Point-of-Service (POS) Cash Collections (PPM: PA-7)

    Purpose:
    Trending indicator of point-of-service collection efforts

    Value:
    Accelerates cash collections and may reduce collection costs

    Equation and Data Source1:

    Patient POS payments            =          Accounts Receivable
    Total self-pay cash collected                 Accounts Receivable

     

     1Alternative data source is the general ledger transaction code applied to patient POS cash and the general ledger total for all patient (self-pay) cash collected during the month


    Points of Clarification:

    Patient Point-of-Service (POS) Payments

    Point-of-service payments are defined as:

    1) Patient cash (self-pay cash) for a current encounter which is collected prior to, at the time of service, and up to seven days after discharge; and

    2) Patient cash (self-pay cash) for a prior encounter which is collected prior to or at the time of a new service. Note: Prior balance payments received after the current date of service do not count as POS if received any time after the time of current service; thus, the seven-day window does not apply to prior balance payments received after the current date of service.

    Includes:

    • All posted POS payments, including undistributed payments (debit transactions only)
    • Cash collected on prior encounters, including cash collected on bad debt accounts, at the current pre-service or time-of-service visit
    • Pre-admit dollars captured in the month payment is posted rather than received
    • Combined hospital/physician payments, if included in denominator2

    Excludes:

    • Refunds; cash refunded to the patient should not be considered
    • Routine payment plan payments unless collected at time of service

    Self-Pay Cash Collected

    Total cash collected for patient responsibility for the reporting month.

    Includes:

    • All patient cash collected for the month reported from patient cash account (debit transaction only)
    • All posted self-pay payments, including undistributed payments
    • Bad debt recoveries
    • Loan payments
    • Combined hospital/physician payments, if included in the numerator2

    2If only reporting hospital data, physician payments included only for Medicare recognized hospital-based status clinics; if only reporting physician/ambulatory payments, exclude hospital payments for non-physician/non-ambulatory payments. If reporting combined hospital and physician data, report all qualified POS collections.If reporting at the integrated delivery system level, all self-pay cash collected across the system is included.

    Total Charge Lag Days (PPM: PB-4)

    Purpose:
    Trending indicator of charge capture workflow efficiency

    Value:
    Impacts cash flow

    Equation and Data Source:

    Σ days from service date to
    posting date (by Charge/CPT code)    =   Patient Financial System
         Σ Charge/CPT codes billed                      Patient Financial System

     

    Points of Clarification:

    Restricted Use: This key is not to be added to data from accounts, i.e., hospital, physician, ambulatory, and/or post-acute that are included in the data reported in PB-1 and PB-2. If physician, ambulatory and/or post-acute accounts are not included in PB-1 and PB-2, this key may be used for those accounts only as a timeliness proxy indicator of charge posting timeliness.

    Sum of Days From Service Date (Revenue Recognition Date) to Charge Posting Date

    The number of days between the date of service and the date of revenue recognition (posting) for each charge code on the claim. This is also known as the elapsed days between revenue posting date and service date. This is not a total of the charges but rather a count of days.

    Sum of the Count of Charge Codes/CPT billed

    This is a count of the number of charge codes billed, not a summation of dollars billed

    Aged A/R as a Percentage of Total Billed A/R (PPM: AR-1)

    Purpose:
    Trending indicator of receivable aging and collectability

    Value:
    Indicates revenue cycle effectiveness at liquidating A/R

    Equation and Data Source:

    0-30, 31-60, 61-90, 91-120, > 120 day   =   Aged Trial Balance
                        Total billed A/R                               Aged Trial Balance

     

    Points of Clarification:

    Billed A/R By Aging Category

    (0-30, 31-60, 61-90, 91-120, > 120 days)

    Total billed A/R1 amount for all payers in each aging category, aged from discharge date (inpatient) or date of service (outpatient/ambulatory/ physicians). Aging buckets are mutually exclusive categories and must sum to 100%. 

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts; see DNFB Key for definition
    • In-house accounts
    • In-house interim-billed accounts
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)

    1Billed A/R at the account level; does not include In-house or DNFB

    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

    Billed A/R

    Total billed A/R1 amount for all payers in reporting month, aged from discharge date (hospitals) or date of service (ambulatory/physicians)

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts; see DNFB Key for definition
    • In-house accounts
    • In-house, interim-billed accounts
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)

    1Billed A/R at the account level; does not include In-house or DNFB

    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

     

    Aged A/R as a Percentage of Billed A/R by Payer Group (PPM: AR-2)

    Purpose:
    Trending indicator of receivable collectability by payer group

    Value:
    Indicates revenue cycle effectiveness at liquidating A/R by payer group

    Equation and Data Source:

    Billed A/R by payer group by aging category   =   Aged Trial Balance
                     Total billed A/R by payer group                Aged Trial Balance

     

    Points of Clarification:

    Billed A/R By Payer Group By Aging Category

    Total billed A/R1 amount by payer in each aging category, aged from discharge date (hospitals) or date of service (ambulatory/physicians/post acute). Aging buckets are mutually exclusive categories and must sum to 100%.

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts
    • In-house accounts
    • In-house interim-billed accounts not billed at month-end
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)

    1Includes in-house and DNFB, billed A/R in standard again categories

    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

     

    Total Billed A/R By Payer Group

    Total billed A/R1 amount by payer in reporting month, aged from discharge date (hospitals) or date of service (hospitals/ambulatory/physicians).

    Includes:

    • Only active billed debit balance accounts; “active billed accounts” are only those accounts that are open
    • Series accounts/recurring accounts
    • Includes accounts outsourced to a third party but not classified as bad debt accounts, as, for example, early out accounts and payment plan accounts

    Excludes:

    • Active billed credit balance accounts; these should be removed from the data2
    • Discharged Not Final Billed (DNFB) accounts; see DNFB Key for definition
    • In-house accounts
    • In-house, interim-billed accounts not billed at month-end
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)

    1Billed A/R at the account level; does not include In-house or DNFB

    2The exclusion applies to the total account balance, not to individual payer and patient components of the balance. Only if the total account balance is a credit should it be excluded.

    Remittance Denial Rate (PPM: AR-5)

    Purpose:

    Trending indicator of % of claims denied

    Value:

    Indicates provider’s ability to comply with payer requirements and payers’ ability to accurately pay the claim; efficiency and quality indicator

    Equation and Data Source:

    Total number of claims denied       =    Accounts Receivable1
    Total number of claims remitted          835 Files and/or Paper Remittance

     

    1Includes in-house and DNFB, billed A/R in standard again categories

    Points of Clarification:

    Number of Claims Denied

    Total claims adjudicated monthly at claim level. Denials are defined as “actionable denials” - those denials that may be addressed and corrected within the organization and may result in appropriate reimbursement.

    Includes:

    • Only payments containing a denial code on the remittance advice2
    • Both initial claim denials and subsequent appeal denials
    • Zero payment and partial payment accounts containing a denial indicator

    Excludes:

    • Denials for plan excluded (non-covered) services-Discharged Not Final Billed (DNFB) accounts
    • Denials for patient responsibility
    • RAC recoupments
    • Denials for duplicate claims
    • Shadow/encounter claims
    • Any account not yet billed to the payer or patient (not considered part of billed A/R)

    2HFMA may provide generic CARC and group code mappings; providers should verify applicability by payer; transaction codes may be used to capture individual actionable denials or reporting and work queue purposes. However, the volume reported is defined as number of claims, not number of line items denied.

     

    Number of Claims Remitted

    Total claims remitted monthly. Remitted claims can be received electronically or through paper process. If 835 data is not accessible, use total insurance payment volumes at the account level. Any report that counts line item detail should not be used; this metric uses the claim as the correct unit to count.

    Net Days in Accounts Receivable (A/R) (PPM: FM-1)

    Purpose:
    Trending indicator of overall A/R performance

    Value:
    Indicates revenue cycle (RC) efficiency

    Equation and Data Source:

                                 Net A/R                                      =    Balance Sheet
    Average daily net patient service revenue            Income Statement

      

    Points of Clarification:

    Net A/R

    Net A/R is the net patient receivable on the balance sheet. It is net of credit balances, allowances for uncollectible accounts, discounts for charity care, and contractual allowances for third-party payers.

    Includes:

    • A/R receivables outsourced to third-party company but not classified as bad debt
    • A/R related to patient specific third-party settlements; a “patient specific settlement” is a payment applied to an individual patient account
    • CAH payments and settlements

    Excludes:

    • A/R related to non-patient specific third-party settlements; a “non-patient specific settlement” is payment that is not applied directly to a patient account; it may appear as a separate, lump sum payment unrelated to a specific account.
    • Non-patient A/R
    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Any state or county subsidy, ambulance services, tax and match type assessments, retail pharmacy, post-acute services.
    • Capitation and/or premium revenue related to value or risk based payer contracts

     

    Average Daily Net Patient Service Revenue

    Most recent three-month daily average of total net patient service revenue. Net patient service revenue is defined as gross patient service revenue minus contractual allowances, minus charity care provision, then minus the provision for doubtful accounts. Note: Gross patient service revenue does not appear on the audited income statement.

     

    Most recent three months is defined as the number of days in the three months including the last month being reported. For example, data submitted for the three months ending June 30 includes April (30 days), May (31 days) and June (30 days) for a total of 91 days used to calculate the average daily net patient service revenue.

    Excludes:

    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Capitation and/or premium revenue related to value or risk based payer contracts

    Cash Collections as a Percentage of Net Patient Service Revenue (PPM: FM-2)

    Purpose:
    Trending indicator of revenue cycle ability to convert net patient services revenue to cash

    Value:
    Indicates fiscal integrity/financial health of the organization

    Equation and Data Source:

    Total patient service cash collected                       =     General Ledger
    Average monthly net patient service revenue            Income Statement

     

    Points of Clarification:

    Patient Service Cash Collected

    Total patient service cash collected for the reporting month, net of refunds

    Includes:

    • All Patient Service payments posted to patient accounts, including undistributed payments
    • Bad debt recoveries

    Excludes:

    • Non-patient-related settlements/payments; examples: capitation
    • Non-patient cash; example: retail pharmacy

     

    Average Monthly Net Patient Service Revenue

    Most recent three-month average of total net patient service revenue. Net patient service revenue is defined as gross patient service revenue minus contractual allowances, minus charity care provision, then minus the provision for doubtful accounts. Note: Gross patient service revenue does not appear on the audited income statement.

     

    Most recent three months is defined as the most recent three months including the last month being reported.

    Excludes:

    • 340B drug purchasing program revenue if NOT recognized as a patient receivable in the patient accounting system
    • Capitation and/or premium revenue related to value or risk based payer contracts

    Primary Care Practice Operating Margin Ratio (PPM: PFM-1)

    Purpose:

    Measures the financial performance of a primary care physician entity on an accrual basis

    Value:

    Determines the state of financial health and sustainability of current practice operations

    Equation and Data Source:

    Net income from primary care practice operations   =    Income Statement
                 Primary care practice operating revenue              Income Statement

     

    Points of Clarification:

    Net Income From Primary Care Practice Operations

    Practice expenses include all operating expenses, including but not limited to advertising/marketing, medical supplies, office supplies, staff salary, staff benefits, provider salary, provider benefits, malpractice, rent/lease and building expenses, furniture/equipment, central support services (IT, billing, HR, finance)

     

    Primary Care Practice Operating Revenue

    Includes all revenue from patient care services delivered by primary care physicians, advanced practice providers, other operations and government appropriations within a specific practice’s operation

     

    Specialty Practice Operating Margin Ratio (PPM: PFM-2)

    Purpose:

    Measures the financial performance of a specialty physician entity on an accrual basis

    Value:

    Determines the state of financial health and sustainability of current practice operations

    Equation and Data Source:

    Net income from specialty practice operations   =    Income Statement
              Specialty practice operating revenue                 Income Statement    

     

    Points of Clarification:

    Net Income From Specialty Practice Operations

    Practice expenses include all operating expenses, including but not limited to advertising/marketing, medical supplies, office supplies, staff salary, staff benefits, provider salary, provider benefits, malpractice, rent/lease and building expenses, furniture/equipment, central support services (IT, billing, HR, finance)

     

    Specialty Practice Operating Revenue

    Includes all revenue from patient care services delivered by specialty care physicians, advanced practice providers, other operations and government appropriations within a specific practice operation

    Net Income (Investment) per Primary Care FTE Physician (PPM: PFM-3)

    Purpose:

    Measures the average profit or loss of primary care FTE physician on an accrual basis

    Value:

    Determines the financial health on a physician FTE level; can be used for tracking and trending the profitability of the entity based on a physician level; supports the need for strategy development to minimize losses

    Equation and Data Source:

    Net income from primary care practice operations   =    Income Statement
          Number of primary practice FTE physicians                 Income Statement      

     

    Points of Clarification:

    Net Income From Primary Care Practice Operations

    Practice expenses include all operating expenses, including but not limited to advertising/marketing, medical supplies, office supplies, staff salary, staff benefits, provider salary, provider benefits, malpractice, rent/lease and building expenses, furniture/equipment, central support services (IT, billing, HR, finance)

     

    Number of Primary Care Practice FTE Physicians

    Includes:

    • Includes Advanced Practice Providers
    • FTE is defined as 40 hours of patient care (Medicare definition)

    Net Income (Investment) per Specialty FTE Physician (PPM: PFM-4)

    Purpose:

    Measures the average profit or loss of a specialty FTE physician on an accrual basis

    Value:

    Determines the financial health on a physician FTE level; can be used for tracking and trending the profitability of the entity based on a physician level; supports the need for strategy development to minimize losses

    Equation and Data Source:

    Net income from specialty practice operations    =    Income Statement
     Number of specialty practice FTE physicians             Income Statement

     

    Points of Clarification:

    Net Income From Specialty Practice Operations

    Practice expenses include all operating expenses, including but not limited to advertising/marketing, medical supplies, office supplies, staff salary, staff benefits, provider salary, provider benefits, malpractice, rent/lease and building expenses, furniture/equipment, central support services (IT, billing, HR, finance)

     

    Number of Specialty Practice FTE Physicians

    Includes:

    • Includes Advanced Practice Providers
    • FTE is defined as 40 hours of patient care (Medicare definition)

    Total Primary Care Practice Physician Compensation as a Percentage of Primary Care Practice Operating Revenue (PPM: PFM-5)

    Purpose:

    Demonstrates an ability to afford primary care physician compensation in relation to the revenue of the physician enterprise

    Value:

    Predicts reasonableness of primary care physician compensation relative to operating revenue (direct contribution of a physician)

    Equation and Data Source:

    Total primary care practice physician compensation   =    Income Statement
            Primary care practice operating revenue                       Income Statement

     

    Points of Clarification:

    Total Primary Care Practice Physician Compensation

    Total compensation includes salary, bonus, and benefits paid in the reporting month

    Excludes:

    • Professional malpractice insurance

     

    Primary Care Practice Operating Revenue

    Includes all revenue from patient care services delivered by primary care physicians, advanced practice providers, other operations and government appropriations within a specific practice’s operation

    Total Specialty Practice Physician Compensation as a Percentage of Specialty Practice Operating Revenue (PPM: PFM-6)

    Purpose:

    Demonstrates an ability to afford specialty physician compensation in relation to the revenue of the physician enterprise

    Value:

    Predicts reasonableness of specialty physician compensation relative to operating revenue (direct contribution of a physician)

    Equation and Data Source:

    Total specialty practice physician compensation   =   Income Statement
               Specialty practice operating revenue                   Income Statement

     

    Points of Clarification:

    Total Specialty Practice Physician Compensation

    Total compensation includes salary, bonus, and benefits paid in the reporting month

    Excludes:

    • Professional malpractice insurance

     

    Specialty Practice Operating Revenue

    Includes all revenue from patient care services delivered by specialty care physicians, advanced practice providers, other operations and government appropriations within a specific practice operation

  • MAP Keys Compliant Program

    HFMA’s MAP Keys Compliant Program evaluates and designates products with data-capture and data-reporting capabilities that support the use of MAP Keys to track, compare, and improve revenue cycle performance. See the details.