Hammer Map Kpis Hfma Nj 11 Jan 2011

HFMA-NJ’s PFS Quarterly MeetingWoodbridge Hilton – 11 January 2011

Key Performance Indicators (KPIs):Strategies for a High-Performance

Revenue Cycle

David Hammer – PartnerAccenture Health & Public Services Practice

Fort Lauderdale, FL

1

Content and Organization

IntroductionKey Performance IndicatorsHFMA’s MAP Initiative

Organization and ManagementHFMA MAP

MAP InitiativeMAP Award

Key Performance IndicatorsPerformance Measurement ConceptsKPI HierarchyLevel I, II, III, and IV KPIs

2

Content and Organization (cont’d)

Metric-Driven Revenue CycleAppendix 1: MAP Keys – 19 DefinitionsAppendix 2: KPIs by Functional Area

Best Practice Performance StandardsBest Practice ProcessesCall to Action

3

Even the VERY BEST Keep Score!

“In business, words are words, explanations are

explanations, promises are promises, but only

performance is reality.”

Harold S. GeneenFormer President and CEO of ITT

4

“If you can’t measure it, you can’t manage it.”

Michael BloombergMayor of New York City and

CEO of Bloomberg, Inc.

Even the VERY BEST Keep Score!

5

Where’s Your Focus?

6

What is a Key Performance Indicator?Numerical factorUsed to quantitatively measure performance

Activities, volumes, etc.Business processesFinancial assetsFunctional groupsThe entire revenue cycle

SOURCE: BearingPoint, Key Performance Indicators

KPI Introduction

7

Purposes of KPIsView a snapshot of performance at an individual, group, department, hospital, or regional levelAssess the current situation and determine root causes of identified problem areasSet goals, expectations, and financial incentives for any individual or groupTrend the performance of the selected individual or group over time

SOURCE: BearingPoint, Key Performance Indicators

KPI Introduction

HFMA’s PATIENT FRIENDLY BILLING® ProjectThe KPI Connection

8

To identify revenue cycle characteristics or processes

with the most impact on value to consumers and hospitals

HFMA’s PATIENT FRIENDLY BILLING® Project Standards of Excellence: Goal

9

Organizational culture that elevates the importance of the revenue cycle

Be good at what you need to be good at

Accelerate improvements – take action and execute

“Must Haves”

10

HFMA’s PATIENT FRIENDLY BILLING® Project Standards of Excellence: Findings

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A picture’s worth a thousand words…

12

Organization and ManagementStructure and Function

Information Technology

Customer Service

Patient Access

• Scheduling• Pre-Reg• Registration• Verification

Revenue Integrity

• Charge capture

• Coding• CDM• Contracting

Billing

• Unbilled control

• Electronic and manual billing

• Secondary billing

Follow-up

• Large-balance

• Small-balance

• 3rd-party• Self-pay

Cash Control

• Collection• Posting• Payment

analysis• Denials

manage-ment

Bad Debt

• Pre-listing• Account

placement• Agency

tracking

KPIs Reporting

• ATBs• Productivity• Unbilled• Claim

submission• Denials

reasons

REVENUE CYCLE CONTROL POINTS

SOURCE: KPMG

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CHARGECAPTURE& ENTRY

MEDICAL MANAGEMENT

REGISTRATION& POS CASH

COLLECTIONS

PRE-REG & PRE-CERT

(Authorization)

PATIENT &INSURANCE

VERIFICATION

REMITTANCE& DENIAL

MANAGEMENT

CONTRACT MANAGEMENT

CLAIMS &INVOICE

PROCESSINGFIRST &

THIRD-PARTYFOLLOW-UP

MEDICALRECORD &

CODING

SCHEDULING

(RESOURCE,PATIENT

SURGICAL,

SUPPLY)

DATAANALYSIS &REPORTING

MATERIALSMANAGEMENT

REQUESTFOR

SERVICEFINANCIALSERVICES

CLINICALCARE


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DENIAL &APPEAL

MGTSCHEDU-LING

1PRE-REG & PRE-CERT

2

INSVERF

3

REG + POSCOLLEC-

TIONS

4

FINANCIALCOUNS

5


6 MEDICAL MGT

7

CLAIMSUBMIT

9

3RD PARTYFOLLOW-UP

10

PMT + ADJ POSTING

11

13

CONTRACTADMIN

14

DENIALPROCES-

SING

12

MEDICALRECORDS &

CODING

8

Revenue

InformationTechnology

SOURCE: PriceWaterhouse Coopers

PATIENTPatient

RACs &

MICs

Capital Markets

Affiliated & Employed MDs

Employers

HMOs / PPOs

O.I.G & Other Regulators

Financial Institutions

Medicare & Medicaid FIs

HEALTHCARE REFORM

COMPLIANCE

PATIENT

CASH FLOW

COST CONTAINMENT

CONSOLIDATION / STANDARDIZATION

QUALITY-DRIVEN REIMBURSEMENT

SOURCE: PriceWaterhouse Coopers 15


DENIAL &APPEAL

MANAGEMENTSCHEDULING

1PRE-REG & PRE-CERT

2

INSURANCE VERIFICATION

3

FINANCIALCOUNSELING

4

REGISTRATION& POS CASH

COLLECTIONS

5


6 MEDICAL MANAGEMENT

7

CLAIMSSUBMISSION

9

THIRD PARTYFOLLOW-UP

10

PAYMENT POSTING

11

13

CONTRACTNEGOTIATION /

ADMIN.

14

REJECTIONPROCESSING

12

MEDICALRECORDS &

CODING

8

Revenue

InformationTechnology

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What is HFMA’s MAP initiative?

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HFMA’s MAP InitiativeRevenue Cycle Excellence

MAP is a comprehensive performance-improvement strategy

Identify indicatorsTrack and improve performanceRecognize excellenceShare successful practices

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HFMA’s MAP InitiativeWhat is MAP?

Clearly-definedMeasurableDiscerningComparable

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HFMA’s MAP InitiativeWhat are MAP Keys?

MAP Keys are provider-developed revenue cycle key performance indicators

Patient AccessRevenue IntegrityClaims AdjudicationManagement

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HFMA’s MAP InitiativeMAP Keys

MAP Keys focus on key areas of revenue cycle performance

Indicator

Purpose

Value

Calculation

Net days in A/R

Trending indicator of overall A/R performance

Indicates revenue cycle efficiency

Net A/R ÷ Net patient-service revenue

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Purpose | Value | CalculationExample

Manage trendsIdentify opportunitiesPrioritize opportunitiesIndentify successful practices

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Comparing Performance

Industry trends

Performance over multiple time frames

Pre-selected peer groups

Customized peer groups

Source: HFMA’s

Bad Debt vs Charity Care as % of Revenue

Jan 09 Mar 09 May 09 Jul 09 Sep 09 Nov 09

0%

1%

3%

4%

5%

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Comparing Performance:Flexible comparisons for in-depth analysis

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What is HFMA’s MAP Award?

HFMA’s MAP Award recognizes healthcare organizations that achieve revenue cycle excellence and serve as models for the

healthcare industry

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HFMA’s MAP AwardRevenue Cycle Excellence

HFMA’s MAP Keys (KPIs) are the primary metrics used in the applicationBest practices identified in 2009’s PFB® research are incorporated in the MAP Award applicationAdditional criteria to evaluate patient satisfaction are also included

The MAP application evaluates HFMA’s financial-performance MAP Keys, as well as

PATIENT FRIENDLY BILLING® Project criteria

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HFMA’s MAP AwardMAP Application Data Approach

Point-of-Service CollectionsTop-25 quartile: 35%Top-10 decile: 46%

Research% of high performers that cite importance of investing in upstream technologies

% of high performers offering price estimates to patients at registration

Successful practicesUse of sample scripts

Use of dedicated Patient Access trainers

Source: HFMA’s 2010 MAP Award Data

Source: HFMA’s March 2010

POS Collections Comparable Statistics27% Median43.6% Top-Quartile Performance

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HFMA’s MAP AwardSample Insights from High-Performance Organizations

Improvement Opportunity: POS Collections

KPIMETRIC

OVERALLRANGE

TOP 25th

PERCENTILETOP 10th

PERCENTILE

Net Days in A/R 58.9 – 23.2 37.4 32.8

POS Cash Collections 0.0% – 66.0% 35.0% 46.3%

Cash Collections as a Percentage of Adjusted Net Patient-Service Revenue

100.0% – 117.8% 101.8% 104.4%

Total Bad Debt Write-off Percentage

9.47% – 0.29% 1.30% 0.90%

Days in DNFB 13.50 – 0.13 6.3 2.7

Patient Satisfaction Score 51 – 95% 78% 82%

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HFMA’s MAP AwardSummary of 2010 Results

1. Net Days in Accounts Receivable

2. Over-90 Aged A/R as a Percentage of Billed A/R

3. Point-of-Service (POS) Cash Collections

4. Cash Collections as a Percentage of Adjusted Net Patient-Service Revenue

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HFMA’s MAP AwardMAP Keys Selected for 2011

5. Total Bad Debt Write-Off Percentage

6. Total Charity Care Write-Off Percentage

7. Days in Total Discharge-Not-Final-Billed (DNFB)

8. Days in Total Final-Billed-Not-Submitted-to-Payer (FBNS)

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HFMA’s MAP AwardMAP Keys Selected for 2011

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How should you measure performance?

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Why Use KPIs?Keep a record and tell a storyBenchmark against your goals and industry best practicesIdentify and manage trends, not single-period resultsIllustrate relationships between KPIs

Key Performance IndicatorsPerformance Measurement Concepts

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Use external, verifiable info sourcesShare the same data with everyone

BoardSenior managementPeersSubordinates

Report both “good” and “bad” results


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Emphasize relative, not absolute KPIsEnable non-manual data extractionRemember, measures drive goal achievementMinimize “budget goal” approachEmbrace “stretch goal” approachLink incentive comp to stretch goals


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Not all KPIs are created equal…

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Level I: Board members, senior execs, financial and clinical directors, and internal reporting for all revenue cycle managers, supervisors, and employeesLevel II: CFO, finance directors and employees, and internal reporting for all revenue cycle managers, supervisors, and employees

Key Performance IndicatorsKPI Hierarchy

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Level III: CFO plus internal reporting for all revenue cycle managers, supervisors, and employeesLevel IV: Internal comparisons of different payors plus external reporting for third party payors

Key Performance IndicatorsKPI Hierarchy

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Key Performance IndicatorsKPI Hierarchy ─ First-Level Indicators

Cash collectionsGross and net A/RIn-House and D-N-F-B receivables3rd-party aging % > 90 daysCash % of net revenueCost to collect %

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Key Performance IndicatorsCash Collections ─ First Level

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Key Performance IndicatorsCash Collections ─ First Level

KPI GOAL M-T-D %

DAYS 20 10 50%

$ $20M $11M 55%

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Key Performance IndicatorsGross A/R ─ First Level

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Key Performance IndicatorsNet A/R ─ First Level

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Key Performance IndicatorsIn-House and D-N-F-B A/R ─ First Level

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Key Performance Indicators3rd-Party Aging % > 90 Days ─ First Level

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Key Performance IndicatorsCash % of Net Revenue ─ First Level

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Key Performance IndicatorsCost-to-Collect % ─ First Level

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Key Performance IndicatorsKPI Hierarchy ─ Second-Level Indicators

Net A/R daysAllowance for doubtful accountsBad debt + charity % of gross revenueDenials % of gross revenueCash % of collection goalPoint-of-service cash % of POS goal

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Key Performance IndicatorsNet A/R Days ─ Second Level

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Key Performance IndicatorsAllowance for Doubtful Accts ─ Second Level

50

Key Performance IndicatorsB/D + Charity % of Gross Rev ─ Second Level

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Key Performance IndicatorsDenials % of Gross Revenue ─ Second Level

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Key Performance IndicatorsA/R Cash % of Cash Goal ─ Second Level

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Key Performance IndicatorsP-O-S Cash % of Goal ─ Second Level

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Key Performance IndicatorsKPI Hierarchy ─ Third-Level Indicators

Credit balance receivables Clean claims throughput %Collection agency netback %Net revenueCase mix index (CMI)Complaints to AdministrationOpen accounts

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Key Performance IndicatorsCredit-Balance Receivables ─ Third Level

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Key Performance IndicatorsClean-Claim Throughput % ─ Third Level

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Key Performance IndicatorsCollection Agency Netback % ─ Third Level

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Key Performance IndicatorsNet Revenue ─ Third Level

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Key Performance IndicatorsCase Mix Index (CMI) ─ Third Level

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Key Performance IndicatorsComplaints to Administration ─ Third Level

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Key Performance IndicatorsOpen Accounts ─ Third Level

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Revenue Cycle KPI reporting sample for:Board of DirectorsFinance CommitteeFinance DivisionInternal reporting

System-wide reporting example MS Access databaseManaged Care “Report Cards” (letters, actually…)

Key Performance IndicatorsManaged Care Report Cards ─ Fourth Level

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By Major Payor Category or Plan Code% of Total A/R >60 Days% of A/R >35 Days (No Pmt, No Response)% of A/R in Underpaid Category% of A/R in Appeal Status% of A/R in Overpaid Category


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MEASUREMENT PEER COMPARISONS SHOWTotal A/R by month Overall A/R trend & direction % A/R >60 days Claims processing issues % A/R >35 days Promptness of payment %/$ Underpaid Contract interpretation issues %/$ Denials under appeal Denial issues %/$ Overpaid Contract interpretation issues


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So… You think you want ametric-driven revenue cycle?

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Key Performance IndicatorsPlanning and Implementing – Key Thoughts

How do you start?Open the discussionTake time to define / refine KPIsGain consensus and commitment

How do you use KPIs to enact change?Understand processes that generate KPIsCreate a culture of accountability and rewardContinuously adapt and iterate

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Key Performance IndicatorsPlanning and Implementing – Key Thoughts

Take the complexity out; simplify your workView key indicators that provide early warningsMaintain personal involvement in critical areasAccess a mix of early-warning and historical data

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Key Performance IndicatorsPlanning and Implementing – Key Questions

Consider the following questionsHow do we enter data?How do we get reports?How do we use information to effect change?When / why are things out-of-control?What do we do?

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Open / frame the discussion 5%Define / refine KPIs 50%Gain consensus / commitment 10%Demand accountability / reward results 25%Continuously adapt and iterate 10%Achieve results! 100%

Key Performance IndicatorsPlanning and Implementing – Call to Action!

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Where’s Your Focus?

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Bibliography

1. “15 Questions to Ask Before Signing a Managed Care Contract,” Private Sector Advocacy, Dec 2002

2. BearingPoint, Key Performance Indicators, Catholic Health East, 20033. Canfield, David and Scott Johnston, HFMA Patient Revenue Cycle

Industry Study, © Healthcare Financial Management Association, Westchester, IL, 2002

4. “Clinical Quality Guidelines,” NEJM, 348:2635-45, June 26, 20035. Guyton, Elizabeth and Chuck Lund, “Transforming the Revenue Cycle,”

Healthcare Financial Management, Mar 20036. Harris, David, “Turning Your Revenue Cycle Into a Hot Rod Using Bolt-

On Technology,” HFMA ANI, Jun 20047. LaForge, Richard and Johnny Tureaud, “Revenue-Cycle Redesign:

Honing the Details,” Healthcare Financial Management, Jan 20038. “Managed Care Forum Contracting Checklist,” HFMA Wants You to

Know, 21 Apr 2004

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Bibliography

9. Miller, Thomas, “Conducting a Managed Care Contract Review,” Healthcare Financial Management, Jan 1998

10. Pogue, Neil – CMS Program Office, “Medicare Policy Update,” HFMA’s Revenue Cycle Strategies Conference, San Francisco, 09 Oct 2007

11. Schneider, Robert, Sheldon Mandelbaum, Ken Braboys, and Cynthia Bailey, “Process-Centered Revenue Cycle Management Optimizes Payment Process,” Healthcare Financial Management, Jan 2001

12. Stevenson, Paul, “Managed Care Cycle Provides Contract Oversight,” Healthcare Financial Management, Mar 2002

13. Walters, Roy, “Five Steps to Great Revenue Cycle Management,” Healthcare Financial Management, May 2002

14. Wennberg, John, E. Fisher, T. Stukel and S. Sharp, “Use of Medicare Claims Data to Monitor Provider-Specific Performance Among Patients with Severe Chronic Illness,” Journal of Health Affairs, 07 Oct 2004

15. Wilson, David, “3 Steps to Profitable Managed Care Contracts,” Healthcare Financial Management, May 2004

David Hammer, Partner, AccentureMr. Hammer is a Senior Executive (Partner) in Accenture's Health and Public Services Practice, specializing in revenue cycle management and health reform. He serves many of the largest health systems, MD-led clinics, and academic medical centers in the US. Prior to joining Accenture, David was VP of enterprise revenue management at McKesson, the nation's largest healthcare IT firm, and was previously the chief revenue officer for Charter Behavioral Health, a +100-facility health system. David has over 28 years of professional experience in healthcare, including executive leadership and direction, revenue cycle transformation, information system planning / implementation, and consulting. He has worked for a variety of leading health systems, software vendors, and professional services firms.

Background and AffiliationsMr. Hammer received an MBA in Management and an MHS in Health Care Administration from the University of Florida. He also received a BBA in Accounting with a minor in Information Systems (Magna cum Laude) from the University of North Florida. Mr. Hammer is certified by HFMA as a Fellow (FHFMA) and as a Certified Healthcare Finance Professional (CHFP). He has been named an HFMA Distinguished Speaker for seven consecutive years, and is a 2007 recipient of HFMA’s Medal of Honor service award.

Recent PublicationsMr. Hammer’s most recent publication is “Health Reform: Intended and Unintended Consequences,” which appeared in the October 2010 issue of HFMA’s healthcare financial management journal (hfm). “Don’t Panic: CFOs React to the New Economic Reality,” appeared in hfm’s March 2009 issue. Mr. Hammer authored the February 2008 cover story in hfm, entitled “Beyond Bolt-Ons – Breakthroughs in Revenue Cycle Information Systems.” He also wrote the July 2007 cover story, called “The Next Generation of Revenue Cycle Management,” as well as the July 2005 hfm cover story, entitled “Performance is Reality: Is Your Revenue Cycle Holding Up?” Another one of his articles, “UPMC’s Metric-Driven Revenue Cycle,” appeared in the September 2007 issue of hfm, and “Data and Dollars: How CDHC is Driving the Convergence of Banking and Health Care” was published in hfm’sFebruary 2007 issue. His article “Black Space Versus White Space – The New Revenue Cycle Battleground” appeared in the January 2007 issue, and “Customer Service Adapts to CDHC” appeared in the September 2006 issue.

Contact InformationMr. Hammer can be reached by telephone at (954) 648-4764 and/or by e-mail at [email protected] or at [email protected]

Instructor’s Bio

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mailto:[email protected]

mailto:[email protected]

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Appendices – MAP Key Definitions and Detailed KPIs

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Definitions of HFMA’s MAP Keys…

Indicator

Purpose

Value

Calculation

Net days in A/R

Trending indicator of overall A/R performance

Indicates revenue cycle efficiency

Net A/RAverage Daily Net Patient

Service Revenue

HFMA’s MAP InitiativeMAP Keys: Net Days in A/R

Purpose | Value | Calculation

80

Indicator

Purpose

Value

Calculation

Aged A/R as a percentage of Billed A/R

Trending indicator of receivables collectability

Indicates RC’s ability to liquidate A/R

>30,>60,>90,>120 daysTotal Billed A/R


HFMA’s MAP InitiativeMAP Keys: Aged A/R Percentage of Final-Billed A/R

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Indicator

Purpose

Value

Calculation

Point-of-Service Cash Collections

Trending indicator of point-of-service collection efforts

Indicates potential exposure to bad debt, accelerates cash collections, and can reduce collection costs

POS PaymentsTotal Patient Cash Collected


HFMA’s MAP InitiativeMAP Keys: Point-of-Service Cash Collections ($)

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Indicator

Purpose

Value

Calculation

Cost to Collect

Trending indicator of operational performance

Indicates the efficiency and productivity of RC processTotal RC Cost

Total Cash Collected


HFMA’s MAP InitiativeMAP Keys: Cost to Collect

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Indicator

Purpose

Value

Calculation

Cash Collections as a Percentage of Adjusted Net Patient-Service Revenue

Trending indicator of propensity to convert net revenue to cash

Indicates fiscal integrity / financial health of the organization

Total Cash CollectedAverage Monthly Net Revenue


HFMA’s MAP InitiativeMAP Keys: Cash Percentage of Net Revenue

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Indicator

Purpose

Value

Calculation

Bad DebtTrending indicator of the effectiveness

of self-pay collection efforts and financial counseling

Indicates organization’s ability to collect self-pay accounts and identify payor sources for patients unable to meet financial obligations

Bad Debt Write-OffGross Patient Service Revenue


HFMA’s MAP InitiativeMAP Keys: Bad Debt (%)

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Indicator

Purpose

Value

Calculation

Charity Care

Trending indicator of local ability to pay

Charity Care Write-OffGross Patient Service Revenue


HFMA’s MAP InitiativeMAP Keys: Charity Care (%)

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Indicates organization’s ability to collect self-pay accounts and identify payor sources for patients unable to meet financial obligations

Indicator

Purpose

Value

Calculation

Days in Total Discharged Not Final Billed

Trending indicator of local ability to pay

Indicates RC performance and can identify performance issues impacting cash flow

Gross Dollars in DNFB A/RAverage Daily Gross Revenue


HFMA’s MAP InitiativeMAP Keys: Days in Total DNFB

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Indicator

Purpose

Value

Calculation

Aged A/R as a % of Billed A/R, by Payor Group

Trending indicator of receivables collectability, by payor group

Indicates RC’s ability to liquidate A/R, by specific payor group

Billed Payor Group by Aging (>30,>60,>90,>120 days)

Total Billed A/R by payor group


HFMA’s MAP InitiativeMAP Keys: Aged A/R Percentage of Billed A/R by Payor

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Indicator

Purpose

Value

Calculation

Days in Final Billed Not Submitted to Payor (FBNS)

Trending indicator of claims delayed by payor / regulatory edits in the claims processing system

Track the impact of internal / external requirements for clean claim production, which impact cash flow

Gross Dollars in FBNSAverage Daily Gross Revenue


HFMA’s MAP InitiativeMAP Keys: Days in FBNS

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Indicator

Purpose

Value

Calculation

Days in Total Discharged Not Submitted to Payer (DNSP)

Trending indicator of total claims-generation / submission effectiveness

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

Gross $ in DNFB + Gross $ in FBNSAverage Daily Gross Revenue


HFMA’s MAP InitiativeMAP Keys: Days in DNSP (DNFB + FBNS)

90

Indicator

Purpose

Value

Calculation

Late Charges as % of Total ChargesMeasure of revenue-integrity

effectivenessIdentify opportunities to improve

revenue integrity, reduce avoidable costs, enhance compliance, and accelerate cash flow

Charges with posting dates greater than 3 days from final service dateTotal gross charges


HFMA’s MAP InitiativeMAP Keys: Late Charge Percentage

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Indicator

Purpose

Value

Calculation

Initial Denial Rate – Zero-Pay Claims

Trending indicator of percentage of claims not paid

Indicates provider’s ability to comply with payor requirements and payor’s ability to accurately pay claims

Number of zero-pay claims deniedNumber of total claims remitted


HFMA’s MAP InitiativeMAP Keys: Initial Zero-Pay Denial Rate (#)

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Indicator

Purpose

Value

Calculation

Initial Denial Rate – Partial-Pay Claims

Trending indicator of percentage of claims partially paid (underpaid)

Indicates provider’s ability to comply with payor requirements and payor’s ability to accurately pay claims

Number of partial-pay claims deniedNumber of total claims remitted


HFMA’s MAP InitiativeMAP Keys: Initial Partial-Pay Denial Rate (#)

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Indicator

Purpose

Value

Calculation

Denials Overturned on Appeal

Trending indicator of provider’s success in managing the appeal process

Indicates opportunities for payor and provider process improvement and cash-flow improvements

Number of appealed claims paidTotal number of claims appealed and

finalized or closed


HFMA’s MAP InitiativeMAP Keys: Appeals Success Rate (#)

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Indicator

Purpose

Value

Calculation

Net Days Revenue in Credit BalancesTrending indicator to accurately report

A/R values, ensure regulatory compliance, and monitor overall A/R management effectiveness

Indicates whether credit balances are managed to appropriate levels and are compliant w/ regulatory requirements

Dollars in Credit BalancesAverage Daily Net Patient-Service

Revenue


HFMA’s MAP InitiativeMAP Keys: Net Days in A/R Credits

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Indicator

Purpose

Value

Calculation

Pre-Registration RateTrending indicator of timeliness,

accuracy, and efficiency of patient access processes

Indicates revenue cycle efficiency and effectiveness

Number of patient encounterspre-registered

Number of scheduled patientencounters


HFMA’s MAP InitiativeMAP Keys: Pre-Registration Rate

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Indicator

Purpose

Value

Calculation

Insurance Verification Rate

Indicates revenue cycle process efficiency and effectiveness

Total number of verified encountersTotal number of registered encounters


HFMA’s MAP InitiativeMAP Keys: Insurance Verification Rate

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Trending indicator of timeliness, accuracy, and efficiency of patient access processes

Indicator

Purpose

Value

Calculation

Service-Authorization Rate

Indicates revenue cycle process efficiency and effectiveness

Number of encounters authorizedNumber of encounters requiring

authorization


HFMA’s MAP InitiativeMAP Keys: Service-Authorization Rate

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Trending indicator of timeliness, accuracy, and efficiency of patient access processes

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Let’s get down to details…

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SchedulingPre-Registration / Pre-AuthorizationInsurance VerificationPatient Access / RegistrationFinancial CounselingHealth Information ManagementCharge Entry / Revenue Protection

KPIs by Functional Area

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Billing / Claim Submission3rd-Party and Guarantor Follow-UpCashiering / Refunds / Adj PostingDenialsCustomer ServiceCollection / Outsourcing VendorsPhysician Practice ManagementManaged Care Contracting

KPIs by Functional Area

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KPIs by Functional AreaScheduling

KPI Description Standard1. Overall scheduling rate of potentially-eligible patients: 100%

Scheduling rate for elective and urgent inpatients 100%

Scheduling rate for ambulatory surgery patients 100%

Scheduling rate for hi-$ outpatient diagnostic patients 100%

2. Scheduled patients’ pre-registration rate 98%

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KPI Description Process

1. Use on-line scheduling software house-wide? Yes

2. Have central scheduling unit? Yes

3. Central scheduling answers to Chief Revenue Officer? Yes

4. Surgery uses same scheduling software as other depts? Yes

5. Scheduling system integrated with registration system? Yes

6. Use on-line OP medical necessity system prior to service? Yes

7. Pre-certification requirements shared with MDs’ offices? Yes


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8. MDs and patients able to make on-line appt requests? Yes

9. Non-emergency services scheduled 12+ hours in advance? Yes

10. Process and IT integrated between scheduling and pre-reg? Yes

11. Services postponed if not pre-authorized in advance? Yes

12. Financial counseling part of scheduling process? Yes

Patient balances and payment obligations discussed? Yes

Hospital policy for point-of-service payment explained? Yes

Reminder to bring required payment & insurance cards given? Yes


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KPIs by Functional AreaPre-Registration / Pre-Authorization

KPI Description Standard1. Overall pre-registration rate of scheduled patients ≥ 98%

2. Overall insurance verification rate of pre-registered patients ≥ 98%

3. Deposit request rate for co-pays and deductibles ≥ 98%

4. Deposit request rate for elective admissions / procedures ≥ 100%

5. Deposit request rate for prior unpaid balances ≥ 98%

6. Data quality compared to pre-established dept standards ≥ 99%

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KPIs by Functional AreaPre-Registration / Pre-Authorization


1. Have dedicated pre-registration / pre-authorization unit? Yes

2. Process and IT integrated between scheduling and pre-reg? Yes

3. Services postponed if not pre-authorized in advance? Yes

4. Financial counseling part of pre-reg / pre-auth process? Yes

Patient balances and payment obligations discussed? Yes



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KPIs by Functional AreaInsurance Verification

KPI Description Standard

1. Overall insurance verification rate of scheduled patients ≥ 98%

2. Overall ins verification rate of pre-registered patients ≥ 98%

3. Ins verf rate of unscheduled IPs w/in one day ≥ 98%

4. Ins verf rate of unscheduled hi-$ OPs w/in one day ≥ 98%


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1. Have dedicated insurance verification unit? Yes

2. Process and IT integrated between ins verf / patient access? Yes

3. Use on-line insurance verification system? Yes

4. Financial counseling part of insurance verification process? Yes

Alternate arrangements for non-covered patients explored? Yes



KPIs by Functional AreaInsurance Verification

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KPIs by Functional AreaPatient Access / Registration


1. Average registration interview duration ≤ 10 min

2. Average patient wait time ≤ 10 min

3. Average IP registrations per registrar / per shift 35

4. Average OP registrations per registrar / per shift 40

5. Average ER registrations per registrar / per shift 40


7. ABNs / MSPQs obtained when required 100%

8. MPI duplicates created daily as a % of total registrations ≤ 1%

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1. Patient Access reports to Chief Revenue Officer? Yes

2. All registrars report to Patient Access or within rev cycle? Yes

3. Use on-line document imaging system? Yes

4. Financial counseling part of patient access process? Yes

Patient balances and other payment obligations collected? Yes

Policy for payment alternatives explained (credit cards, etc.)? Yes

Copies of required payment & insurance cards obtained? Yes

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5. Registrars’ incentive compensation tied to quality indicators? Yes

6. Registration system integrated / interfaced to PFS system? Yes

7. Use on-line / web-enabled patient self-registration system? Yes

8. Use on-line OP medical necessity system prior to service? Yes

9. Use on-line registration data quality tracking system? Yes

10. Have on-line interface to owned MDs’ registration system? Yes


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KPIs by Functional AreaFinancial Counseling


1. Collection of elective services deposits prior to service 100%

2. Collection of IP patient-pay balances prior to discharge ≥ 65%

3. Collection of OP patient-pay balances prior to service ≥ 75%

4. Collection of ER patient-pay balances prior to departure ≥ 50%

5. Screening of uninsured IPs and hi-bal OPs for fin assist ≥ 98%

6. Pmt arrangements for non-charity eligible IPs / hi-bal OPs ≥ 98%

7. Prompt-payment discount percentage(s) 05 – 20%

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1. Financial counseling reports to Chief Revenue Officer? Yes

2. Uninsured IPs and high-balance OPs screened for fin assist? Yes

Medicaid eligibility? Yes

State, local, and hospital charity programs? Yes

Grants / studies, etc.? Yes

3. Financial counselors interview patients in their rooms? Yes

4. Prompt payment discounts offered? Yes

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5. Fin counselors’ incentive compensation tied to collections? Yes

6. Discuss pmt alternatives w/ non-charity eligible patients? Yes

Credit cards? Yes

Bank-loan financing? Yes

Interest-bearing hospital-funded payment arrangements? Yes

7. All IPs cleared thru financial counselors before discharge? Yes

8. Proof of income / assets obtained from charity applicants? Yes

115

KPIs by Functional AreaHealth Information Management

KPI Description Standard1. IP charts coded per coder / per day 20 - 24

2. OBSV charts coded per coder / per day 32 - 36

3. AMB SURG charts coded per coder / per day 32 – 36

4. OP charts coded per coder / per day 130 – 210

5. ER charts coded per coder / per day 130 - 210

6. Chart delinquency greater than 30 days ≤ 5%

7. Total chart delinquency ≤ 10%

116



8. HIM “DRG development” hold greater than late charge hold ≤ 2 A/R days

9. Copies of medical records pursuant to payors’ requests ≤ 2 work days

10. Transcription rate per line 08 – 12¢

11. Transcription backlog ≤ 1 work day

12. Chart retrieval pursuant to MDs’ requests ≤ 90 minutes

13. MPI duplicates as a % of total MPI entries ≤ .5%

14. PEPPER1 potential “over-codes” beyond 75th percentile ≤ 2%

15. PEPPER potential “under-codes” below 10th percentile ≤ 2%

1 Program for Evaluation Payment Patterns Electronic Report

117



1. Health Info Management reports to Chief Revenue Officer? Yes

2. Use on-line DRG and APC groupers? Yes

3. Use on-line, bar-code enabled chart location system? Yes

4. Use on-line, scanning-enabled HIM records imaging system? Yes

5. Use on-line and/or voice-recognition transcription system? Yes

6. Use on-line clinical abstracting system ? Yes

7. MDs able to view and/or e-sign records outside the hospital? Yes

118



8. Storage / retrieval / release of records HIPAA-compliant? Yes

9. Use on-line, up-to-date coding compliance system? Yes

10. All coding done by employees reporting to HIM Director? Yes

11. All coding done by certified coders who are retrained often? Yes

12. All coding done in descending balance order, not FIFO ? Yes

13. All coding done in “best payor” order (FFS, MCR, HMO)? Yes

14. All coding done when info is sufficient, not 100% complete? Yes

119



15. Receive and discuss denials info provided by PFS or others? Yes

16. Provide and discuss denials / delinquency info with MDs? Yes

17. Have effective tracking system to locate missing records? Yes

18. Have appropriate staffing to prevent process backlogs? Yes

19. Consistently monitor / control D-N-F-B A/R due to HIM? Yes

20. Perform internal quality-control audits at least quarterly? Yes

21. Have external quality-control audits done at least annually? Yes

120



22. Review PEPPER to compare MCR pmts w/ state & nat’l avgs? Yes

23. Use PEPPER to identify problem-prone DRGs? Yes

24. Use PEPPER / OIG Work Plans to focus internal reviews? Yes

25. Track / trend all outside record-audit requests? Yes

26. Self-review all charts selected for audit by RACs / others? Yes

27. Submit all self-reviews w/ “Things Done Right” cover letters? Yes

121

KPIs by Functional AreaCharge Entry / Revenue Integrity


1. Late charge hold period 2 – 4 days

2. Late charges as a % of total charges ≤ 2%

3. Lost charges as a % of total charges ≤ 1%

4. CDM duplicate items 0

5. CDM incorrect / missing HCPCS / CPT-4 codes 0

6. CDM incorrect / invalid revenue codes 0

7. CDM revenue code lacks necessary HCPCS / CPT-4 code 0

122



8. CDM item has invalid / incorrect modifier 0

9. CDM item has missing modifier 0

10. CDM item price less than HOPPS APC rate 0

11. CDM item price is $0 0

12. CDM item description is “Miscellaneous” 0

13. CDM item description / price is editable on-line 0

123



1. CDM Coordinator reports to Chief Revenue Officer? Yes

2. Have formal CDM change management process? Yes

3. Have formal annual CDM review process with clinical depts? Yes

4. Modifiers “static coded” in CDM; chosen via order-entry sys? Yes

5. All charge items ordered via on-line order-entry system? Yes

6. Late / lost charge perf stds in dept mgrs’ job descriptions? Yes

7. Annual HCPCS / CPT-4 changes in place by Jan each year? Yes

124



8. Surgery HCPCS / CPT-4 appear in UB-04 form locator 44? Yes

9. Surgery lab / X-ray charges properly unbundled? Yes

10. CDM pricing methodology standardized / defensible? Yes

11. Depts understand difference between “billable” / “payable?” Yes

12. CDM items have Patient Friendly Billing® descriptions? Yes

13. Have formal annual charge sheet / ticket review process? Yes

14. Receive / review CPT-4 manual / Addendum B annually? Yes

125



15. Nursing procedures (CPR, infusion, etc.) built into CDM? Yes

16. HIM assigns interventional / surgical procedure codes? Yes

17. ER Nursing levels match Medicare descriptions? Yes

18. MDs’ OP orders received with requisite CPT-4 code(s)? Yes

19. Order entry items map accurately to service codes? Yes

20. Charge tickets, etc. map accurately to service codes? Yes

21. Appropriate charge in CDM for all services delivered? Yes

126



22. Charge data flow reliably from points of service to claims? Yes

23. Modifiers are conveyed correctly / reliably to claims? Yes

24. CCI edit conflicts controlled by correct reg / charge entry? Yes

25. Units of service accurate / flow reliably to claims? Yes

26. Clinical depts’ “charge awareness” monitored / enhanced? Yes

127

KPIs by Functional AreaBilling / Claim Submission


1. HIPAA-compliant electronic claim submission rate 100%

2. Final-billed / claim not submitted backlog ≤ 1 A/R day

3. Medicare supplement ins billing following adjudication ≤ 2 bus days

4. Non-Medicare COB-2 ins billing following COB-1 payment ≤ 2 bus days

5. Medicare RTP (Return To Provider) denials rate ≤ 3%

6. Outsourced guar stmt cost to produce / mail (w/out stamp) 20 - 25¢

128



1. Primary / secondary billing completed by dedicated team? Yes

2. Staffing sufficient to minimize / prevent billing backlogs? Yes

3. Quantity / quality perf stds part of billers’ job descriptions? Yes

4. Perform regular quality control reviews of billers’ work? Yes

5. All billers finish CMS’s Medicare billing training? Yes

6. All billers receive annual Medicare compliance training? Yes

7. Billers cross-trained on more than one payor type? Yes

129


KPI Description Process8. Use on-line electronic billing system? Yes

Easy to add new billing edits? Yes

Automatic daily downloads from PFS system? Yes

Provides final-bill download reconciliation reports? Yes

Provides biller-specific worklists? Yes

Major-payor edits supplied / supported by vendor? Yes

Claim-submit notice automatically uploaded to PFS system? Yes

Claim corrections automatically uploaded to PFS system? Yes

130



8. Use on-line electronic billing system (con’t)? Yes

All claims (paper + electronic) editable? Yes

Standard errors automatically corrected? Yes

Provides biller-specific productivity and error reporting? Yes

Provides clinical department-specific error reporting? Yes

Automates Medicare-supplement / COB-2 claim submission? Yes

Interfaces with on-line Medicare-compliance system? Yes

131



9. Use Patient Friendly Billing® concepts for guarantor billing? Yes

10. Use proration to bill ins and guarantor simultaneously? Yes

11. Guarantor stmts include credit card option? Yes

12. Guarantor stmts clearly communicate payment policies? Yes

13. Guarantor stmts provide customer service phone number? Yes

14. Guarantor stmts provide customer service web address? Yes

15. Guarantor billing cycle designed to optimize collections? Yes

132

KPIs by Functional Area3rd-Party and Guarantor Follow-Up


1. Ins A/R aged more than 90 days from service / discharge ≤ 15 - 20%

2. Ins A/R aged more than 180 days from service / discharge ≤ 5%

3. Ins A/R aged more than 365 days from service / discharge ≤ 2%

4. Bad debt write-offs as a % of gross revenue ≤ 3%

5. Charity write-offs as a % of gross revenue ≤ 3%

6. Cost-to-collect ([PA + PFS + agency expenses] ÷ cash) ≤ 3%

7. A/R cash as a % of net revenue ≥ 100%

133



8. In-House A/R days ≤ ALOS

9. D-N-F-B A/R days ≤ 4 – 6 A/R days

10. Net A/R days ≤ 50 A/R days

11. A/R cash as a % of cash goal ≥ 100%

12. Total point-of-service cash as a % of cash goal ≥ 2 - 3%

134



1. High-balance follow-up completed by dedicated team? Yes

2. Staffing sufficient to minimize / prevent aged A/R build-up? Yes

3. Quantity / quality perf stds part of collectors’ job descriptions? Yes

4. Perform regular quality control reviews of collectors’ work? Yes

5. All collectors finish CMS’s Medicare billing module? Yes

6. All collectors receive annual Medicare compliance training? Yes

7. Collectors cross-trained on more than one payor type? Yes

135


KPI Description Process8. Use on-line “receivables work station” system? Yes

Easy to add new collector assignments? Yes

Automatic daily downloads from PFS system? Yes

Provides download reconciliation reports? Yes

Full interface for collection notes, etc. to PFS system? Yes

Provides collector-specific worklists? Yes

Worklists presented in descending-balance order? Yes

Next activity date automatically uploaded to PFS system? Yes

136



9. Use on-line, web-enabled 3rd-party payor inquiry system(s)? Yes

10. Guarantor follow-up outsourced or on predictive dialer? Yes

11. Collectors receive 3rd-party / guarantor follow-up training? Yes

12. Collectors use 3rd-party / guarantor follow-up scripts? Yes

13. Collectors have no competing duties (customer svc, etc)? Yes

14. Collectors receive performance-based incentive comp? Yes

137

KPIs by Functional AreaCashiering / Refunds / Adjustment Posting


1. HIPAA-compliant electronic payment posting % 100%

2. Transaction posting backlog (during the month) ≤ 1 bus day

3. Transaction posting backlog (end of the month) 0 bus days

4. Credit-balance A/R days (gross) ≤ 2 A/R days

5. Medicare credit-balance report submission timeliness ≤ due date

138



1. Cashiering completed by dedicated team w/ no other duties? Yes

2. Refunds completed by dedicated team w/ no other duties? Yes

3. Quantity / quality perf stds part of cashiers’ job descriptions? Yes

4. Perform regular quality control reviews of cashiers’ work? Yes

5. All cashiers receive annual Medicare compliance training? Yes

6. Cashiers cross-trained on more than one payor type? Yes

139



8. Use lockbox for non-electronic / non-EDI payments? Yes

9. Lockbox remits payment data electronically / EDI / OCR / 835? Yes

10. Denial transaction codes entered to facilitate follow-up? Yes

11. Use on-line system to compare expected vs. actual pmts? Yes

12. Post contractual adjustments at time of final billing? Yes

140

KPIs by Functional AreaDenials / Underpayments


1. Overall initial denials rate (% of gross revenue) ≤ 4%

2. Clinical initial denials rate (% of gross revenue) ≤ 5%

3. Technical initial denials rate (% of gross revenue) ≤ 3%

4. Underpayments additional collection rate ≥ 75%

5. Appealed denials overturned rate 40 – 60%

141



6. Electronic eligibility rate ≥ 75%

7. Physician pre-certification double-check rate 100%

8. Case managers’ time spent securing authorizations rate ≤ 20%

9. Total denial reason codes ≤ 25

142



1. Denials tracked by payor, reason, financial consequence? Yes

2. Denials distinguished between technical and clinical? Yes

3. Denials tracked by physician, DRG, and department? Yes

4. Contractual allowances increasing slower than gross rev? Yes

5. Dedicated denials unit w/ payor-specific appeals experience? Yes

6. Respond to clinical documentation requests w/ in 14 days? Yes

7. Use on-line system to compare expected vs. actual pmts? Yes

143



8. Use on-line payment tracking software? Yes

9. Use on-line contract management software? Yes

10. Maintain denials database; self-developed or purchased? Yes

11. Use on-line OP med necessity system prior to billing or svc? Yes

12. All denial reason codes actionable? Yes

13. OBSV and IP authorizations tracked separately? Yes

14. Pre-cert, auth, and re-cert functions in a single department? Yes

144



15. Pre-certification requirements shared with MDs’ offices? Yes

16. Provide MDs with regular feedback on clinical denials rates? Yes

17. Hold regular payor meetings to discuss denials issues? Yes

18. Contract terms regularly distributed to rev cycle employees? Yes

19. Rev cycle employees learn of contract changes in advance? Yes

20. Structured feedback between rev cycle and mgd care depts? Yes

21. Non-emergency services scheduled 12+ hours in advance? Yes

145

KPIs by Functional AreaCustomer Service


1. Correspondence backlog ≤ 1 bus day

2. Walk-in patients’ wait time ≤ 5 min

3. ACD system average hold time ≤ 2 min

4. ACD system abandoned call % (calls on hold ≥ 30 seconds) ≤ 2%

5. ACD system % of calls answered in ≤ 20 seconds ≥ 75%

6. ACD system % of calls resolved in ≤ 5 minutes ≥ 85%

7. ACD system % of calls not resolved in ≥ 10 minutes ≤ 5%

8. Calls resolved in unit, w/out complaint / referral to Dir PFS ≥ 95%

146



1. Cust service handled by dedicated team w/ no other duties? Yes

2. CS unit responsible for walk-ins, phone calls, mail, & e-mail? Yes

3. Quantity / quality perf stds part of CS reps’ job descriptions? Yes

4. Perform regular quality control reviews of CS reps’ work? Yes

5. All CS reps receive annual Medicare compliance training? Yes

6. CS reps cross-trained on more than one responsibility? Yes

147



7. CS reps cross-trained on most / all PFS system functions? Yes

8. Use voice-mail sys so patients can request basic info / IBs? Yes

9. Use ACD (Automated Call Distribution) system? Yes

10. ACD system automatically maintains unit / rep statistics? Yes

148

KPIs by Functional AreaCollection / Outsourcing Vendors


1. Bad debt netback ([collections – fees] ÷ placements) % 7 – 11%

2. Bad debt fee % 15 – 18%

3. 3rd-party EBO (Extended Bus Ofc) fee % (IP + OP + ER blend) 6 - 10%

4. Self-pay EBO fee % (IP + OP + ER blend) 10 – 12%

5. Legal collections fee % 20 – 30%

6. Medicaid eligibility assistance fee % 12 – 18%

149



1. Use two or more bad debt agencies? Yes

2. Use different agencies for bad debt and EBO? Yes

3. Write off long-term payment accts / use agency to monitor? Yes

4. Apply Medicare bad debt “120 days” rule to all fin classes? Yes

5. Agencies / outsource vendors accept referrals electronically? Yes

6. EBO vendor able to “mirror” PFS system to get notes, etc.? Yes

7. Medicaid elig vendor have good relations w/ State agencies? Yes

150



8. Agencies remit gross payments / submit invoices for fees? Yes

9. Agencies willing to put own support FTEs on-site? Yes

10. Agencies willing to assign dedicated FTEs to your accounts? Yes

151

KPIs by Functional AreaPhysician Practice Management


1. Visits w/out charges as % of total visits 0%

2. Co-pay collections as % of total co-pay office visits ≥ 95%

3. EDI claims as % of total claims ≥ 90%

4. Charge-entry lag period ≤ 1 bus day

5. Claims passing claim edits as % of total claims ≥ 98%

6. Appointment no-show rate ≤ 2 - 3%

152



7. Appointment bumped rate ≤ 2 - 3%

8. Net A/R days (non-specialty practices) ≤ 40 days

9. Collections as % of net revenue ≥ 100%

10. Collections as % of gross revenue (non-specialty practices) ≥ 60%

11. 3rd-Party A/R aging > 90 days from service date ≤ 10%

12. Denials as % of net revenue (including “incidental to” svcs) ≤ 2%

153



13. Claims w/ no activity > 90 days from last activity date 0%

14. Credit balances ≤ 2 A/R days

15. Average patient wait time after office arrival ≤ 15 minutes

154



1. Send voice and mail reminders for regular annual visits? Yes

2. Send voice and mail reminders for other scheduled visits? Yes

3. Use “open scheduling” Yes

to increase walk-in capacity? Yes

to minimize appointment bumping? Yes

to increase patient satisfaction? Yes

to reduce nursing callbacks? Yes

155



4. Calculate net revenue and net receivables? Yes

5. Use dedicated billing / follow-up FTEs w/ no other duties? Yes

6. Use collection agencies? Yes

Let’s pause and define terms...Contracting Cycle

156

157

1. Provide patients

4. Pay claims

2. Treat patients

3. Submit claims

KPIs by Functional AreaContracting Cycle Definition

158

Reduce Payor Discretion

Achieve Target Margins


159

AnalyzeService Lines

Understand Payors & Their Reputations

Analyze Steerage vs.

Discounts

Submit & Follow-up

Claims

Work Denials &Payment Variances

Collect Accounts & Post Payments

Analyze Financial

Needs

Define Payor’s & Provider’s Duties

Understand Competitors

& Market

Negotiate Contract Language & Rates

Analyze Contract

Performance


160

Strategy developmentStrategy implementationContract negotiationsContract evaluationForecasting and analysisContract implementation and operationsPerformance monitoringStrategic issues and planning

SOURCE: Stevenson, “Managed Care Cycle Provides Contract Oversight,” hfm


161

KPI Description Standard1. Rate increases compared to CPI medical-care component ≥ CPI MCC

2. Outlier $ fraction of total contract revenue ± 5%

3. Contract profitability compared to IRR “hurdle rate” ≥ IRR HR

4. Eligibility / authorization / certification availability 24 / 7 / 365

5. Retro review / timely filing periods (keep in balance) 90 – 120 days

6. Termination notification period (without cause) 90 days

7. Renegotiation planning begins prior to renewal date 6 months

8. Optimal contract term 2 – 3 years

KPIs by Functional AreaManaged Care Contracting

162

KPI Description Process1. Contract contains automatic renewal clause? Yes

2. Contract contains inflation index? Yes

3. All hospital services included / specific exclusions defined? Yes

4. Termination notification period = 90 days? Yes

5. Duties for on-going patient care / pmt at termination defined? Yes

6. ABN or equivalent acceptable for non-covered services? Yes7. Provider authorized to bill guarantor for non-covered svcs? Yes8. Hospital-based MDs use hospital-obtained authorizations? Yes

SOURCE: “Managed Care Forum Contracting Checklist,” HFMA Wants You to Know


163

KPI Description Process9. Provider authorized to collect deposits for non-covered svcs? Yes

10. Contract discloses all sub-contracting relationships? Yes

11. Contract contains an independent contractor clause? Yes

12. Contract excludes “most favored nation” provisions? Yes

13. Contract start date clearly defined (to prevent A/R build up)? Yes

14. Contract stipulates all parties pay own legal fees? Yes

15. Definition / criteria for all key terms clearly stipulated? Yes

Medical necessity? Yes

Emergency condition / emergency admission? Yes



164

KPI Description Process15. Definition / criteria for all key terms clearly stipulated (con’t)? Yes

Trauma / trauma services / trauma team? Yes

Covered services? Yes

Material breach? Yes

Prompt payment? Yes

Stop-loss / outlier? YesCarve-out? Yes

Medicare rate? (should include pass-throughs) Yes



165


Sentinel event(s)? Yes

Medical-loss ratio? Yes

Silent PPO? Yes

Clean claim? Yes

Timely notification / timely filing? YesAuthorization / certification? Yes



166


Service level(s)? Yes

Denial / rejection / null event? Yes

Negotiation / mediation / arbitration? Yes

Plan agreement? Yes

Inpatient / outpatient / emergency patient / obsv patient? Yes

Substantial impact? Yes

Member / insured / dependent? Yes



167

KPI Description Process16. Advance notice time for contract changes clearly stipulated? Yes

Payment / reimbursement rates? YesCovered services / procedures? Yes

Plan documents / requirements? Yes

Major employer groups? Yes

17. Contract includes warranty of HIPAA compliance? Yes

18. Contract forbids reassignment without mutual consent? Yes

19. Payor’s reporting requirement duties clearly stipulated? Yes



168

KPI Description Process20. Contract clearly material to provider’s revenue stream? Yes21. Eligibility verification process clearly stipulated? Yes22. Medical necessity verification process clearly stipulated? Yes

23. Prior authorization process clearly stipulated? Yes

24. Payor provides all customers’ contract / policy manuals? Yes

25. Payor provides copies of all administrative / policy manuals? Yes

26. Appeal / independent review processes clearly stipulated? Yes

27. Payor precluded from changing reimbursement unilaterally ? Yes

SOURCE: “15 Questions to Ask Before Signing a Managed Care Contract,” Private Sector Advocacy


169

KPI Description Process28. Payor’s prompt payment duty clearly stipulated? Yes29. Payor agrees to pay interest on late payments? Yes30. Contract complies with statutory processing / pmt duties? Yes

31. Payor precluded from “takebacks” / “offsets”? Yes

32. “Retro review” period balanced to “timely filing” period? Yes

33. Contract precludes participating in / enabling “Silent PPOs”? Yes

34. Termination provisions / timing clearly stipulated? Yes

35. Contract terms supersede provisions in Provider Manual? Yes

SOURCE: “15 Questions to Ask Before Signing a Managed Care Contract,” Private Sector Advocacy


170

KPI Description Process36. Perform annual “internal” analysis of all contracts? Yes

Contractual discounts balanced to gross volumes / net rev? YesUse analysis to identify renegotiation / termination targets? Yes

Compare all contracts to Medicare fee schedule? Yes

Calculate relative profitability using payor-specific costs? Yes

All contracts cover their direct costs, at minimum? Yes

Use relative profitability for leverage during renegotiation? Yes

Recognize internal review cannot I.D. below-mkt contracts? Yes

Recognize internal review silent on case mix/stop-loss/etc.? Yes

SOURCE: Wilson, David et al, “3 Steps to Profitable Managed Care Contracts,” hfm


171

KPI Description Process37. Perform annual “external” analysis of all contracts? Yes

Compare (legally) your rates to those of similar providers? YesUse outside firms / databases to obtain comparative info? Yes

Challenge data’s age / geographic relevance before using? Yes

Compare specific service lines, as well as overall rates? Yes

Target biggest upside opportunities during renegotiation? Yes

Compare pmt structures (charge % / DRGs) + overall rates? Yes

Understand impact of I/P stop-loss / O/P max-pay clauses? Yes

Try to end all “cost-plus” pmts in favor of % of charges? Yes



172

KPI Description Process37. Perform annual “external” analysis of all contracts (con’t)? Yes

Review contract language, especially key terms / clauses? YesClaim submission and payment Yes

Protection against catastrophic cases Yes

Procedure-based carve-out payments Yes

Stop-loss payment structures Yes

Pmts for implants / prosthetics / orthotics / high-$ drugs Yes

Cut-off date for timely filing / retro review / refunds / etc. Yes

Utilization review process Yes

New services / technologies Yes



173

KPI Description Process37. Perform annual “external” analysis of all contracts (con’t)? Yes

Compare payment levels to premium increases? YesEnsure rate trends mirror premium increase trends? Yes

Compare payors’ relative profitability trends? Yes

Compare rate trends to medical-care component of CPI? Yes



174

KPI Description Process38. Conduct annual “pmt performance” analysis of all contracts? Yes

Contracts comply with statutory processing / pmt regs? YesReport habitual violators to Insurance Commissioner? Yes

Compare payors’ denial / pmt discrepancy trends, by group? Yes

Insurance plan? Yes

Patient type? Yes

Service line? Yes

Reason code? Yes

Physician? Yes



175

KPI Description Process39. Contract defines documentation req’d to prove timely filing? Yes40. Contract reviewed by attorney before renewal? Yes41. “Soft” contract provisions (“quality” / “affordable”) avoided? Yes

42. “Reasonable efforts” term used to define providers’ duties? Yes

43. Both parties agree not to disclose negotiated rates? Yes

44. Supplemental documents included by reference / attached? Yes

45. Amendments required in writing with mutual signatures? Yes

46. Participating corporations / entities clearly stipulated? Yes

47. Assignment clauses clearly stipulated / require signatures? Yes

SOURCE: Miller, Thomas, “Conducting a Managed Care Contract Review,” Healthcare Financial Management


176

KPI Description Process48. “Start up” payors post security deposit / letter of credit / etc? Yes49. Contract parties independent and able to compete? Yes50. Provider listed as “participating” in directories / websites? Yes51. Complete list of covered services attached to contract? Yes

52. Provider can reduce malpractice ins to state law minimums? Yes

53. Ambiguous service descriptions avoided? Yes

Avoid “services including but not limited to” Yes

Avoid “services customarily provided” Yes

Avoid “services covered by the plan” Yes



177

KPI Description Process54. Services not directly provided defined / contracted in adv? Yes

Out-of-area services YesHospital-based physician services Yes

55. Capitation rates / benefits design (if any) clearly stipulated? Yes

56. Flat-rate contracts w/ payors known for excessive bundling? Yes

57. Licensing / JCAHO standards adequate for credentialing? Yes

58. Provider not required to report “in accordance with HEDIS?” Yes

59. Contract / payment terms administratively feasible? Yes

60. Current HIS adequate to handle contract terms / A/R needs? Yes



178

KPI Description Process61. Mutual information requirements clearly stipulated? Yes

Specific information / reports described? Yes“Information including but not limited to” avoided? Yes

Provider’s confidential / proprietary information protected? Yes

Provider’s duty to provide info to payor strictly limited? Yes

Payor obligated to reimburse costs of providing records? Yes



179

KPI Description Process62. Mutual duties regarding care reviews clearly stipulated? Yes63. Provider’s duty to notify payor re: adverse events limited? Yes

No duty re: patient complaints? Yes

No duty re: risk management incidents? Yes

No duty re: physician malpractice suits? Yes

No duty re: physician status changes? Yes

No duty re: medical staff disciplinary actions? Yes

Notify only when sued by members at time of event? Yes

Notify only on intent to report adverse event to regulators? Yes



180

KPI Description Standard1. P4P Demonstration Project percentile ranking ≥ 80%

2. P4P Demonstration Project bonus achievement ≥ 1%

3. Length of stay, by DRG ≤ DRG avg

4. Readmission rate, by DRG ≤ DRG avg

5. Adherence to quality indicators, by condition ≥ 80%

6. Adherence to quality indicators, by mode ≥ 80%

7. Overall P4P program ROI ≥ 0%

KPIs by Functional AreaP4P: Clinical Decision Support / Finance

181

KPI Description Process1. Use advanced clinical systems to support patient care? Yes

2. Use electronic medical record system to support patient care? Yes

3. Use advanced decision support / performance mgt system? Yes

4. Use executive information (scorecard) system? Yes

5. Use “data warehouse” to support DSS / EIS capabilities? Yes

6. Participate in CMS Demonstration Project, if eligible? Yes

7. Have clinical improvement teams in data-enabled depts? Yes

8. Target greatest cost / quality improvement areas first? Yes

9. Use “root cause analysis” to focus improvement efforts? Yes

KPIs by Functional AreaP4P: Clinical Decision Support / Finance

Hammer Map Kpis Hfma Nj 11 Jan 2011

Documents

snapshot of performance

map keys

revenue cycle characteristics

entire revenue cyclesource

selected individual

largebalance smallbalance

financial incentives

regional level