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:

  1. start collecting data
  2. trend the data over time (weekly, monthly, quarterly, annually)
  3. 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:

Productivity Tracking

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

Billing Productivity

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.

Collection Productivity

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

Biller/Collector Productivity

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