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NHIA Reimbursement Training Center
Key Performance Indicators (KPIs)/ Metrics
Key Performance Indicators, goals and trending should be based on the needs of your organization. NHIA does not have benchmark data for these indicators, mainly because they can vary significantly amongst home and specialty infusion companies based on therapy mix, payer mix, contract terms, staffing, company size and structure, and other factors.
If you currently do not have Key Performance Indicators (KPIs), or metrics: determine what it is you want to measure and then:
start collecting data
trend the data over time (weekly, monthly, quarterly, annually)
look to data trends for opportunities for improvement
Common Reimbursement/ Finance KPIs
Productivity: Measures daily/weekly/monthly production base on the role/function
Accounts Receivable (AR) Aging Buckets: Trends how the AR is aging month to month
Cash Posted by Aging Bucket: Trends what bucket cash collections falls into
Adjustment Type/Amount: Trend adjustments by amount and reason code
Payer Aging >90,>120,>180: Trends how a specific payer’s AR is trending
Payments by Payer: Trends how much you are getting paid per month per payer
DSO by Bill or Service Date: Month over month determines how quickly “sales” are collected.
Trending Example: Cash Posted by Aging bucket over the last 12 months
Step 1: Enter the Aging buckets across the top
Step 2: Enter the Month/Year list in a single column
Step 3: Run your system report and enter the data each month (generally after end of month close)
Trending will reflect cash collection efforts towards AR. Is only 50% of current? If so you may have a billing or payer issue. Is 90% of current yet your AR >120 isn’t coming down? Then likely there is a collection issue (staffing, payer, system, etc.)
Productivity options vary, a few options are listed below:
Things to consider before creating Productivity Goals
The functions each team member performs
Payor Mix: Contract, Out of Network, Medicare, PBM, etc.
Ability and/or “newness” of each team member
Tools Available to the Team: Payer sites, ERN Capability, System functions, Processors
Current staffing level
Assumes the sole function of the role is Billing Primary and Secondary claims, with no collection activity
Payer assignment (instead of an alpha split) allows for expertise to be developed
Consider payer billing requirements when reviewing productivity
Paper claims and/or claims requiring attachments may decrease productivity
Productivity based on an Invoice count versus a dollar amount billed may be a more effective measure
Measures can be set daily, weekly or monthly
PBM invoices and autogenerated patient copay invoices should rarely be included when reviewing a Biller’s productivity unless that is the sole responsibility of the biller. These claims are quickly generated and may skew the productivity data if not removed.
Assumes the sole function of the role is “insurance” collections or “patient” collections
Payer assignment (instead of an alpha split) allows for expertise/accountability
Determine and communicate what counts as a collection “action”
Add defined headers, subject headings or notes to help determine what actions are being taken to resolve the AR
Standardization is key
Productivity is measured by the number of collection “actions” taken and not necessarily the by dollars produced
The reason for this is the same amount of time is generally needed to appeal a $500 claim as is a $2,500 claim.
A separate Cash Goal may be established per collector or for the team as whole.
Cash Goal Examples:
60 Day Net Lagged Revenue (claims billed 2 months ago)
60 Day Net Lagged Revenue + 10% of the >90 AR (or >120, or >180)
Your options are open, but should remain realistic for your business
Assumes the role is to both bill claims and collect on outstanding AR
The overall though process with this method is “accountability”
Downfall with this mix is that people tend to gravitate toward either Billing or Collecting which may cause laxity or a lessor effort in one of the areas
Medicare is often billed/collected by the same person due to the nuances with Medicare
The same billing and collection actions noted above would hold true as if they were separate
Productivity would be a combination of the two actions
Cash Posting Productivity
Assumes both posting and adjustment transactions
Assignment is flexible (by day, batch, site, system, etc.)
Productivity measures should consider manual versus auto posting capabilities
Auto posting transactions should be 2-3 times higher than manual posting
Measuring the number of transactions per day allows for equality in the measure
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