HFMA MAP Keys Patient Access Measure:

Transcription

1 HFMA MAP Keys Patient Access Pre-Registration Rate Trending indicator that patient access processes are timely, accurate, and efficient Indicates revenue cycle efficiency and effectiveness N: number of patient encounters preregistered D: number of scheduled patient encounters Insurance Verification Rate Trending indicator that patient access functions are timely, accurate, and efficient Indicates revenue cycle process efficiency and effectiveness N: total number of verified encounters D: total number of registered encounters Service Authorization Rate Trending indicator that patient access functions are timely, accurate, and efficient Indicates revenue cycle process efficiency and effectiveness N: number of encounters authorized D: number of encounters requiring authorization 1

2 HFMA MAP Keys Patient Access Point-of-Service (POS) Cash Collections Trending indicator of point-of-service collection efforts Indicates potential exposure to bad debt, accelerates cash collections, and can reduce collection costs N: POS payments D: total patient cash collected Conversion Rate of Uninsured Inpatient to Payer Source Trending indicator of qualifying uninsured inpatients for a funding source Indicates organization s ability to successfully secure funding for uninsured inpatients and improve customer satisfaction N: total inpatient cases approved D: total uninsured inpatient discharges 2

3 HFMA MAP Keys Revenue Integrity Days in Total Discharged Not Final Billed (DNFB) Trending indicator of claims generation process Indicates revenue cycle performance and can identify performance issues impacting cash flow N: Gross Dollars in A/R (Not Final Billed) D: Average Daily Gross Revenue Days in Total Discharged Not Submitted to Payer (DNSP) Trending indicator of total claims generation and submission process Indicates revenue cycle performance and can identify performance issues impacting cash flow N: Gross Dollars in DNFB + Gross Dollars in FBNS D: Average Daily Gross Revenue 3

4 HFMA MAP Keys Revenue Integrity Late Charges as a Percentage of Total Charges Measure of revenue capture efficiency Identify opportunities to improve revenue capture, reduce unnecessary cost, enhance compliance, and accelerate cash flow N: charges with post date greater than three days from last service date D: total gross charges Net Days Revenue in Credit Balance Trending indicator to accurately report account values, ensure compliance with regulatory requirements, and monitor overall payment system effectiveness Indicates whether credit balances are being managed to appropriate levels and are compliant to regulatory N: Dollars in Credit Balance D: Average Daily Net Patient Services Revenue 4

5 HFMA MAP Keys Claims Adjudication Days in Final Billed Not Submitted to Payer (FBNS) Trending indicator of claims impacted by payer/regulatory edits within claims processing system Track the impact of internal/external requirements to clean claim production, which impacts positive cash flow N: Gross Dollars in FBNS D: Average Daily Gross Revenue UB04 (8371) Clean Claim Rate Trending indicator of claims data as it impacts revenue cycle performance Indicates quality of data collected and reported N: number of claims that pass edits requiring no manual intervention D: total claims accepted into claims scrubber tool for editing prior to submission 5

6 HFMA MAP Keys Claims Adjudication Initial Denial Rate Zero Pay Trending indicator of % claims not paid Indicates provider s ability to comply with payer requirements and payer s ability to accurately pay the claim N: number of zero paid claims denied D: number of total claims remitted Initial Denial Rate Partial Pay Trending indicator of % claims partially paid Indicates provider s ability to comply with payer requirements and payer s ability to accurately pay the claim N: number of partially paid claims denied D: number of total claims remitted 6

7 HFMA MAP Keys Claims Adjudication Denials Overturned by Appeal Trending indicator of hospital s success in managing the appeal process Indicates opportunities for payer and provider process improvement and improves cash flow N: number of appealed claims paid D: total number of claims appealed and finalized or closed Denial Write-Offs as a Percent of Net Revenue 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 Indicates provider s ability to comply with payer requirement and payers ability to accurately pay the claim N: net dollars written off as denials D: Net Patient Services Revenue 7

8 HFMA MAP Keys Management Net Days in Accounts Receivable Trending indicator of overall A/R performance Indicates revenue cycle efficiency N: Net A/R D: Average Daily Net Patient Service Revenue Aged Accounts Receivable (A/R) as a Percentage of Billed A/R Trending indicator of receivable collectability Indicates revenue cycle s ability to liquidate A/R N: >30, >60, >90, >120 days D: Total Billed A/R Aged A/R as a % of Billed A/R by Payer Group Trending indicator of receivable collectability by payer group Indicates revenue cycle s ability to liquidate A/R by payer group N: Billed Payer Group by Aging (>30, >60, >90, >120 days) D: Total Billed A/R by payer group 8

9 HFMA MAP Keys Management Cash Collection as a Percentage of Adjusted Net Patient Services Revenue Trending indicator of revenue cycle to convert net patient services revenue to cash Indicates fiscal integrity/financial health of the organization N: Total Cash Collected D: Average Monthly Net Revenue Bad Debt Trending indicator of the effectiveness of self-pay collection efforts and financial counseling Indicates organization s ability to collect self-pay accounts and identify payer sources for those who can t meet financial obligations N: Bad Debt Write-Off D: Gross Patient Service Revenue 9

10 HFMA MAP Keys Management Charity Care Trending indicator of local ability to pay Indicates services provided to patients deemed unable to pay N: Charity Care Write-Off D: Gross Patient Service Revenue Charity as a Percent of Uncompensated Care Trending indicator that monitors charity care versus bad debt Reflection of charity care (provided to the community) N: charity care D: Total Uncompensated Care (Bad debt + Charity Care) Cost to Collect Trending indicator of operational performance Indicates the efficiency and productivity of revenue cycle (RC) process N: Total RC Cost D: Total Cash Collected 10

11 HFMA MAP Keys Management Cost to Collect by Functional Area Trending indicator of operational performance by functional area as reported in KPI 4 (Cost to Collect) Indicates the efficiency and productivity of revenue cycle process by functional area N: Total x (x = the cost of each functional area) cost* D: total cash collected *Sum total of all x s (i.e. sum of the cost of each functional area) should equal total cost of KPI 4 Case Mix Index Trending indicator of patient acuity, clinical documentation, and coding Supports appropriate reimbursement for services performed and accurate clinical reporting N: CMI (average RW/Patient) = Sum of relative weights for all patients* D: Number of patients in the month* *Excludes normal newborns and Medicare-exempt units 11

12 HFMA MAP Keys Physician Practice Management Percent of Patient Schedule Occupied Identifies opportunity to maximize slot utilization and improve practice productivity Measures available capacity in a patient schedule N: Number of patient hours occupied D: Number of patient hours available Point-of-Service (POS) Collection Rate Provides opportunity to increase collections, decrease collection costs, and accelerate cash flow Identifies opportunity for increased POS collections N: Total POS collections D: Total patient cash collected all self-pay Total Charge Lag Days Measures charge capture workflow efficiency and identifies delays in cash Accelerates cash flow N: Σ days from revenue recognition date (posting date) less date of service date (by CPT code) D: Σ CPT codes billed 12

13 HFMA MAP Keys Physician Practice Management Professional Services Denial Percentage Tracks payer denials and impact on cash flow and trends payment opportunity and process improvement Drives root cause accountability in the revenue cycle processes N: Σ CPT (units of service) codes denied D: Σ CPT codes billed Aged A/R by Payer Group as a Percentage of Outstanding Total A/R Trending indicator of receivable aging and collectibility by payer group Indicates payment delays or revenue cycle s ability to liquidate A/R by payer group N: Billed payer group by aging (0-30, >30, >60, >90, >120 days) D: Outstanding A/R by payer group 13

14 HFMA MAP Keys Physician Practice Management Aged A/R as a Percentage of Outstanding A/R Trending indicator of receivable aging and collectibility Indicates payment delays or revenue cycle s ability to liquidate A/R N: 0-30, >30, >60, >90, >120 days D: Total outstanding A/R Primary Physician Practice Operating Margin Ratio Measures the financial performance of a primary physician entity on an accrual basis Determines the state of financial health and sustainability of current practice operations N: Net income from primary practice operations D: Primary practice operating revenue Specialty Physician Practice Operating Margin Ratio Measures the financial performance of a specialty physician entity on an accrual basis Determines the state of financial health and sustainability of current practice operations N: Net income from specialty operations D: Specialty operating revenue 14

15 HFMA MAP Keys Physician Practice Management Net Income/Loss Per Primary FTE Physician Measures the average profit or loss of Primary FTE physician on an accrual basis 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 N: Net income from operations D: Number of FTE physicians Net Income/Loss Per Specialty FTE Physician Measures the average profit or loss of specialty FTE physician on an accrual basis 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 N: Net income from operations D: Number of FTE physicians 15

16 HFMA MAP Keys Physician Practice Management Total Primary Physician Compensation as a Percentage of Net Revenue 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) N: Total primary physician compensation D: Total net primary patient service revenue Total Specialty Physician Compensation as a Percentage of Net Revenue Demonstrates an ability to afford specialty physician compensation in relation to the revenue of the physician enterprise> Predicts reasonableness of specialty physician compensation relative to revenue (direct contribution of a physician) N: Total specialty physician compensation D: Total net specialty patient service revenue 16

17 HFMA MAP Keys Physician Practice Management Practice Net Days in A/R Calculates the average number of days it takes to collect payment on services rendered; measures revenue cycle effectiveness and efficiency 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 N: Net patient service A/R D: Average daily net patient service revenue Practice Cash Collection Percentage Measures revenue cycle efficiency, supports the valuation of current accounts receivable, and predicts income Provides an opportunity to increase cash flow and forecasts accuracy of expected revenues N: Actual patient service cash collections D: Net patient service revenue 17