• MAP Keys for Hospitals and Health Systems

    Pre-Registration Rate (PA-1)

    Purpose:
    Trending indicator that patient access processes are timely, accurate, 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 bolt-on to the PFS system

    Points of Clarification:

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

    Includes:

    • Outpatient encounters – an outpatient account is defined as one encounter; e.g. recurring account counts as one account and one encounter
    • Inpatient admissions and observation cases
    • Canceled pre-registrations
    • Accounts created from any departmental schedule that qualify for pre-registration per provider policy 

    Excludes:

    • Unscheduled pre-admits, including walk-in’s and Emergency/Urgent Care cases

     

    Scheduled Patient Encounters

    Total number of monthly scheduled encounters. A "scheduled encounter" is defined as an encounter scheduled one calendar day or more 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
    • Canceled pre-registrations

    Excludes:

    • Unscheduled pre-admit

    Insurance Verification Rate (PA-2)

    Purpose:
    Trending indicator that patient access functions are timely, accurate, 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 encounters verified within one day of service or date of admission. 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 & Observation (PA-3)

    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. Data should be calculated as the numerator (number of authorized encounters) plus the umber of encounters that were denied due to a lack of authorization, typically for medical necessity.

    Service Authorization Rate-Outpatient (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 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.

    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 ue to a lack of authorization, typically for medical necessity.

    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 Payer Source (PA-5)

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

    Value:
    Indicates organization's ability to successfully secure funding for uninsured patients and improve customer satisfactions

    Equation & Data Source:

    Total uninsured patients converted to insurance   =   Accounts Receivable1
    Total uninsured discharges and visits                            Accounts Receivable
    1Includes vendor reports for outsourced accounts

    Points of Clarification:

    Uninsured Patients (discharges and visits) Converted to Insurance2,3

    Total patient discharges and visits approved in the reporting month.

    Includes:

    • Inpatients converted at any time
    • Outpatients converted after discharge, including ED, should be counted
    • Conversions of normal and non-normal 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 
    2Conversion is counted once valid coverage is verified
    • Must be a third-party funding source; conversions to Charity Care are not counted
    • 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
    3All conversions approved in the reporting month are included in the numerator regardless of discharge rate

     

    Uninsured Discharges and Visits

    The total number of uninsured discharges and visits in the reporting month.

    Point-of-Service (POS) Cash Collections (PA-6)

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

    Value:
    Indicates potential exposure to bad debt, accelerates cash collections, and can 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 patient cash (self pay cash) collected prior to or at time of service and up to seven days after discharge and/or patient cash collected on prior service(s) at the time of a new 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  
    2Physician payments included only for Medicare recognized hospital-based status clinics

     

    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
    2Physician payments included only for Medicare recognized hospital-based status clinics

    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 inpatient and outpatient accounts not 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"

    Excludes:

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

     

    Average Daily Gross Patient Service Revenue
    Monthly gross patient services 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 inpatient and outpatient 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
    • Professional fees, if included on the 837-i claim

    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 services revenue divided by number of days in the reporting month. This is a single month daily average, not a rolling average.

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

    Purpose:
    Trending indicator of total 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

    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 services revenue divided by number of days in the reporting month. This is a single month average, not a rolling average.

    UB04 (8371) 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

    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 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 a Percentage of Total Charges (CL-2)

    Purpose:
    Measure of revenue capture efficiency

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

    Equation & Data Source:

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

    Points of Clarification:

    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 collectability

    Value:
    Indicates revenue cycle effectiveness at liquidating A/R

    Equation & Data Source:

    0-30, 31-60, 61-90, 91-120, >121 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, >121 days)

    Total billed A/R1 amount for all payers in each aging category, aged from discharge date. 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 but 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
    1Billed A/R at the account level
    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.

    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
    1Billed A/R at the account level
    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 Percent 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 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. 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
    1Billed A/R at the account level
    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 billed A/R1 amount by payer 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, as, or example, early out accounts and payment plans

    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
    1Billed A/R at the account level
    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.

    Denial Rate (Zero Pay & Partial Pay) (AR-3)

    Purpose:
    Trending indicator of % claims denied

    Value:
    Indicates provider's ability to comply with payer requirements and payer's 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 result in increased 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 non-covered service
    • Denials for patient responsibility
    • RAC recoupments
    • Denials for duplicate claims
    • Shadow/encounter claims
    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 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 (AR-4)

    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 form lost appeals or choosing not to appeal
    • Dollars must be stated at net

     

    Average Monthly 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 n 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-base status clinic
    • 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.

    Bad Debt (AR-5)

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

    Value:
    Indicates organization's ability to collect self-pay 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-6)

    Purpose:
    Trending indicator of local ability to pay

    Value: 
    Indicates services provided to patients deemed unable to pay

    Equation & 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-7)

    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 & 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-admit
    • In-house 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
    • 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 thirdparty 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
    • 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
    • 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                          =   Balance Sheet
    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
    • Medicare Disproportionate Share Hospital (DSH) payments
    • Indirect Medical Education (IME) payments

    Excludes:

    • Patient-related settlements/payments; examples: capitation, Safety Net, Direct Graduate Medical Education (DGME), Medicare Passthrough, 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

     

    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
    • Capitation and/or premium revenue related to value
    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.

    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 written off 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 bed 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 inpatients.

    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

     

    Discharged Inpatients in the Month

    Monthly discharged inpatient count.

    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

    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. Coding cost includes all facility coding costs and only those professional coding costs associated with provider
      based clinics

    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
    • Indirect Medical Education (IME) payments

    Excludes:

    • Patient-related settlements/payments; examples: capitation, Safety Net, Direct Graduate Medical Education (DGME), Medicare Passthrough, 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

     

    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 = the cost of 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/precertification, 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. Coding cost includes all facility coding costs and only those professional coding costs associated with provider based clinics

    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
    • Indirect Medical Education (IME) payments

    Excludes:

    • Patient-related settlements/payments; examples: capitation, Safety Net, Direct Graduate Medical Education (DGME), Medicare Passthrough, 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

     

  • 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

    Percent of Patient Schedule Occupied

    Purpose:
    Identifies opportunity to maximize slot utilization and improve practice productivity

    Value:
    Measures available capacity in a patient schedule

    Equation:

    N: Number of patient hours occupied
    D: Number of patient hours available

    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Point-of-Service (POS) Collection Rate

    Purpose:
    Provides opportunity to increase collections, decrease collection costs, and accelerate cash flow

    Value:
    Identifies opportunity for increased POS collections

    Equation:

    N: Total POS collections
    D: Total patient cash collected - all self-pay 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Total Charge Lag Days

    Purpose:
    Measures charge capture workflow efficiency and identifies delays in cash

    Value:
    Accelerates cash flow

    Equation:

    N: ∑ days from revenue recognition date (posting date) less date of service date (by CPT code)
    D: ∑ CPT codes billed 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Professional Services Denial Percentage

    Purpose:
    Tracks payer denials and impact cash flow; trends payment opportunity and process improvement

    Value:
    Drives root cause accountability in the revenue cycle processes

    Equation:

    N: ∑ CPT (units of service) codes denied
    D: ∑ CPT codes billed 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Aged A/R by Payer Group as a Percentage of Outstanding Total A/R

    Purpose:
    Trending indicator of receivable aging and collectibility by payer group

    Value:
    Indicates payment delays or 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: Outstanding A/R by payer group
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Aged A/R as a Percentage of Outstanding A/R

    Purpose:
    Trending indicator of receivable aging and collectibility

    Value:
    Indicates payment delays or revenue cycle's ability to liquidate A/R

    Equation:

    N: 0-30, >30, >60, >90, >120 days
    D: Total outstanding A/R 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Primary Physician Practice Operating Margin Ratio

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

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

    Equation:

    N: Net income from primary practice operations
    D: Primary practice operating revenue
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Specialty Physician Practice Operating Margin Ratio

    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:

    N: Net income from specialty operations
    D: Specialty operating revenue 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Net Income/Loss Per Primary FTE Physician

    Purpose:
    Measures the average profit or loss of primary 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:

    N: Net income from primary operations
    D: Number of primary FTE physicians 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Net Income/Loss Per Specialty FTE Physician

    Purpose:
    Measures the average profit or loss of 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:

    N: Net income from specialty operations
    D: Number of specialty FTE physicians 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Total Primary Physician Compensation as a Percentage of Net Revenue

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

    Value:
    Predicts reasonableness of primary physician compensation relative to revenue (direct contribution of a physician)

    Equation:

    N: Total primary physician compensation
    D: Total net primary patient service revenue
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Total Specialty Physician Compensation as a Percentage of Net Revenue

    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 revenue (direct contribution of a physician)

    Equation:

    N: Total specialty physician compensation
    D: Total net specialty patient service revenue 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Practice Net Days in A/R

    Purpose:
    Calculates the average number of days it takes to collect payment on services rendered; measures revenue cycle effectiveness and efficiency

    Value:
    Used as a potential proxy for DCOH (“Cash Inventory”); determines the effectiveness of patient care collections and can be used for budgeting and cash flow projections

    Equation:

    N: Net patient service A/R
    D: Average daily net patient service revenue 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.

    Practice Cash Collection Percentage

    Purpose:
    Measures revenue cycle efficiency, supports the valuation of current A/R, and predicts income

    Value:
    Provides an opportunity to increase cash flow and forecasts accuracy of expected revenues

    Equation:

    N: Actual patient service cash collections
    D: Net patient service revenue 
     
    Expanded information for physician practice management MAP Keys, including inclusions and exclusions, is currently under development.
  • 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.