Accenture - Key Performance Indicators

HFMA-Georgia Fall Institute
Savannah 09 November 2012
Key Performance Indicators (KPIs):

Strategies for a High-Performance
Revenue Cycle
David Hammer, FHFMA
Senior Vice President Revenue Cycle Advisory Solutions
MedAssets Alpharetta, GA
Content and Organization

Introduction
Key Performance Indicators
HFMAs MAP
Performance Measurement Concepts
KPI Hierarchy
Level I, II, III, and IV KPIs
Case Study
Metric-Driven Revenue Cycle
Content and Organization (contd) Appendices

Definitions of HFMAs MAP Keys
KPIs by Functional Area
Best Practice Performance Standards
Best Practice Processes
Call to Action
Even the VERY BEST Keep Score!
In business, words are

words, explanations are
explanations, promises are
promises, but only
performance is reality.
Harold S. Geneen
Former President and CEO of ITT
Even the VERY BEST Keep Score!
If you cant measure it,

you cant manage it.
Michael Bloomberg
Mayor of New York City and
CEO of Bloomberg, Inc.
Organization and Management

Structure and Function
Collection
Denials &
Discrepancies
Pricing
Compliance
Follow-up
Cash
Posting
Billing
Contracting
Registration
Coding
Financial Counseling
SOURCE: St. Vincent Health System, Indianapolis
Organization and Management

Structure and Function
HEALTHCARE
REFORM
COMPLIANCE
O.I.G & Other
Regulators
COST
CONTAINMENT
Financial Institutions
Information
Technology
7
6
CHARGE
CAPTURE
& ENTRY
MEDICAL
MANAGEMENT
8
MEDICAL
RECORDS &
CODING
9
CLAIMS
SUBMISSION
5
REGISTRATION
& POS CASH
COLLECTIONS
10
THIRD PARTY
FOLLOW-UP
RACs
&
MICs
11
PATIENT
FINANCIAL
COUNSELING
PAYMENT
POSTING
CONSOLIDATION /
STANDARDIZATION
Capital
Markets
12
3
INSURANCE
VERIFICATION
Affiliated &
Employed MDs
Medicare &
Medicaid FIs
REJECTION
PROCESSING
2
PRE-REG &
PRE-CERT
Revenue
SCHEDULING
14
CONTRACT
NEGOTIATION /
ADMIN.
Employers
CASH FLOW
SOURCE: PriceWaterhouse Coopers
13
DENIAL &
APPEAL
MANAGEMENT
HMOs /
PPOs
QUALITY-DRIVEN
REIMBURSEMENT
What is HFMAs MAP initiative?
HFMAs MAP Initiative

Revenue Cycle Excellence

What is MAP?
MAP is a comprehensive
performance-improvement strategy
Identify indicators
Track and improve performance
Recognize excellence
Share successful practices

What are MAP Keys?
MAP Keys are provider-developed

revenue cycle key performance indicators
Clearly-defined
Measurable
Discerning
Comparable
10

MAP Keys
MAP Keys focus on key areas of

revenue cycle performance
Patient Access
Revenue Integrity
Claims Adjudication
Management
11

MAP Keys
Purpose | Value | Calculation

Example
Indicator
Net days in A/R
Purpose
Trending indicator of overall A/R performance
Value
Indicates revenue cycle efficiency
Calculation
Net A/R Net patient-service revenue
12

MAP Keys
Comparing Performance
Manage trends
Identify opportunities
Prioritize opportunities
Indentify successful practices
13

MAP Keys
Comparing Performance:
Flexible comparisons for in-depth analysis
Industry trends
Performance over multiple
time frames
Pre-selected peer groups

Customized peer groups
5%
4%
3%
1%
0%
Jan 09
Mar 09
May 09
Jul 09
Sep 09
Nov 09
Bad Debt vs Charity Care as % of Revenue

Source: HFMAs
14
What is HFMAs MAP Award?
15
HFMAs MAP Award
Revenue Cycle Excellence
HFMAs MAP Award recognizes healthcare

organizations that achieve revenue cycle
excellence and serve as models for the
healthcare industry
16
HFMAs MAP Award
MAP Application Data Approach
The MAP application evaluates HFMAs

financial-performance MAP Keys, as well as
PATIENT FRIENDLY BILLING Project criteria
HFMAs MAP Keys (KPIs) are the primary metrics
used in the application
Best practices identified in 2009s PFB research
are incorporated in the MAP Award application
Additional criteria to evaluate patient satisfaction
are also included
17
HFMAs MAP Award
Sample Insights from High-Performance Organizations
Improvement Opportunity: POS Collections

Point-of-Service Collections Research
% of high performers that cite importance

of investing in upstream technologies
Top-25 quartile: 35%

Top-10 decile:
46%
Source: HFMAs 2010 MAP Award Data
POS Collections Comparable Statistics
% of high performers offering price

estimates to patients at registration
Successful practices
27%
Median
Use of sample scripts
43.6%
Top-Quartile Performance
Use of dedicated Patient Access trainers
Source: HFMAs
March 2010
18
How should you measure performance?
19

Why Use KPIs?
Keep a record and tell a story
Benchmark against your goals and industry best
practices
Identify and manage trends, not single-period
results
Illustrate relationships between KPIs
20

Use external, verifiable info sources
Share the same data with everyone
Board
Senior management
Peers
Subordinates
Report both good and bad results
21
Not all KPIs are created equal
22

KPI Hierarchy
Level I: Board members, senior execs, financial and

clinical directors, and internal reporting for all revenue
cycle managers, supervisors, and employees
Level II: CFO, finance directors and employees, and
internal reporting for all revenue cycle managers,
supervisors, and employees
23

KPI Hierarchy
Level III: CFO plus internal reporting for all revenue

cycle managers, supervisors, and employees
Level IV: Internal comparisons of different payors
plus external reporting for third party payors
24
KPI Hierarchy First-Level Indicators
Cash collections
Gross and net A/R
In-House and D-N-F-B receivables
3rd-party aging % > 90 days
Cash % of net revenue
Cost to collect %
25

Cash Collections First Level
26

Cash Collections First Level
KPI
GOAL
M-T-D
DAYS
20
10
50%
$20M
$11M
55%
27

Gross A/R First Level
28

Net A/R First Level
29
In-House and D-N-F-B A/R First Level
30
3rd-Party Aging % > 90 Days First Level
31
Cash % of Net Revenue First Level
32

Cost-to-Collect % First Level
33
KPI Hierarchy Second-Level Indicators
Net A/R days

Allowance for doubtful accounts
Bad debt + charity % of gross revenue
Denials % of gross revenue
Cash % of collection goal
Point-of-service cash % of POS goal
34

Net A/R Days Second Level
35
Allowance for Doubtful Accts Second Level
36
B/D + Charity % of Gross Rev Second Level
37
Denials % of Gross Revenue Second Level
38
A/R Cash % of Cash Goal Second Level
39
P-O-S Cash % of Goal Second Level
40
KPI Hierarchy Third-Level Indicators
Credit balance receivables

Clean claims throughput %
Collection agency netback %
Net revenue
Case mix index (CMI)
Complaints to Administration
Open accounts
41
Credit-Balance Receivables Third Level
42
Clean-Claim Throughput % Third Level
43
Collection Agency Netback % Third Level
44

Net Revenue Third Level
45
Case Mix Index (CMI) Third Level
46
Complaints to Administration Third Level
47

Open Accounts Third Level
48
Managed Care Report Cards Fourth Level

Revenue Cycle KPI reporting sample for:
Board of Directors
Finance Committee
Finance Division
Internal reporting
System-wide reporting example
MS Access database
Managed Care Report Cards (letters, actually)
49

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
50
MEASUREMENT
Total A/R by month
% A/R >60 days
% A/R >35 days
%/$ Underpaid
%/$ Denials under appeal
%/$ Overpaid
PEER COMPARISONS SHOW

Overall A/R trend & direction
Claims processing issues
Promptness of payment
Contract interpretation issues
Denial issues
Contract interpretation issues
51
52
53
54
55
So You think you want a

metric-driven revenue cycle?
56
Planning and Implementing Key Thoughts

How do you start?
Open the discussion
Take time to define / refine KPIs
Gain consensus and commitment
How do you use KPIs to enact change?
Understand processes that generate KPIs
Create a culture of accountability and reward
Continuously adapt and iterate
57
Planning and Implementing Key Thoughts
Take the complexity out; simplify your work

View key indicators that provide early warnings
Maintain personal involvement in critical areas
Access a mix of early-warning and historical data
58
Planning and Implementing Key Questions

Consider the following questions
How 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?
59
Planning and Implementing Call to Action!
Open / frame the discussion

Define / refine KPIs
Gain consensus / commitment
Demand accountability / reward results
Continuously adapt and iterate
Achieve results!
5%
50%
10%
25%
10%
100%
60
Wheres Your Focus?
61
Bibliography
1.
2.
3.
4.
5.
6.
7.
8.
15 Questions to Ask Before Signing a Managed Care Contract, Private

Sector Advocacy, Dec 2002
BearingPoint, Key Performance Indicators, Catholic Health East, 2003
Canfield, David and Scott Johnston, HFMA Patient Revenue Cycle
Industry Study, Healthcare Financial Management Association,
Westchester, IL, 2002
Clinical Quality Guidelines, NEJM, 348:2635-45, June 26, 2003
Guyton, Elizabeth and Chuck Lund, Transforming the Revenue Cycle,
Healthcare Financial Management, Mar 2003
Harris, David, Turning Your Revenue Cycle Into a Hot Rod Using BoltOn Technology, HFMA ANI, Jun 2004
LaForge, Richard and Johnny Tureaud, Revenue-Cycle Redesign:
Honing the Details, Healthcare Financial Management, Jan 2003
Managed Care Forum Contracting Checklist, HFMA Wants You to
Know, 21 Apr 2004
62
Bibliography
9.
10.
11.
12.
13.
14.
15.
Miller, Thomas, Conducting a Managed Care Contract Review,

Healthcare Financial Management, Jan 1998
Pogue, Neil CMS Program Office, Medicare Policy Update, HFMAs
Revenue Cycle Strategies Conference, San Francisco, 09 Oct 2007
Schneider, Robert, Sheldon Mandelbaum, Ken Braboys, and Cynthia
Bailey, Process-Centered Revenue Cycle Management Optimizes
Payment Process, Healthcare Financial Management, Jan 2001
Stevenson, Paul, Managed Care Cycle Provides Contract Oversight,
Healthcare Financial Management, Mar 2002
Walters, Roy, Five Steps to Great Revenue Cycle Management,
Healthcare Financial Management, May 2002
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
Wilson, David, 3 Steps to Profitable Managed Care Contracts,
Healthcare Financial Management, May 2004
63
Instructors Bio
David Hammer, Sr. VP Rev Cycle Advisory Solutions, MedAssets
Mr. Hammer is Senior Vice President of MedAssets Revenue Cycle Advisory Solutions
Practice, specializing in revenue cycle performance improvement, revenue integrity, and
health reform. He serves many of the largest health systems, MD-led clinics, and academic
medical centers in the US. Prior to joining MedAssets, David was a Senior Executive with
Accenture. He has also served as 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 29 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 consulting firms.
Background and Affiliations
Mr. 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 HFMAs Medal of Honor service award.
Recent Publications
Mr. Hammers most recent publication is Health Reform: Intended and Unintended
Consequences, which appeared in the October 2010 issue of HFMAs healthcare financial
management journal (hfm). Dont Panic: CFOs React to the New Economic Reality,
appeared in hfms 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?
Contact Information
Mr. Hammer can be reached by telephone at (954) 648-4764 and/or by e-mail at

dhammer@medassets.com or at david.c.hammer@gmail.com
64
Appendices
65
Definitions of HFMAs MAP Keys
66
MAP Keys: Net Days in A/R

Indicator
Net days in A/R
Purpose
Trending indicator of overall A/R

performance
Value
Indicates revenue cycle efficiency
Calculation
Net A/R
Average Daily Net Patient
Service Revenue
67
MAP Keys: Aged A/R Percentage of Final-Billed A/R

Indicator
Aged A/R as a percentage of Billed A/R
Purpose
Trending indicator of receivables

collectability
Value
Indicates RCs ability to liquidate A/R
Calculation
>30,>60,>90,>120 days
Total Billed A/R
68
MAP Keys: Point-of-Service Cash Collections ($)
Indicator
Point-of-Service Cash Collections
Purpose
Trending indicator of point-of-service

collection efforts
Value
Calculation
Indicates potential exposure to bad

debt, accelerates cash collections,
and can reduce collection costs
POS Payments
Total Patient Cash Collected
69

MAP Keys: Cost to Collect

Indicator
Cost to Collect
Purpose
Trending indicator of operational

performance
Value
Indicates the efficiency and

productivity of RC process
Total RC Cost
Total Cash Collected
Calculation
70
MAP Keys: Cash Percentage of Net Revenue

Indicator
Cash Collections as a Percentage of

Adjusted Net Patient-Service Revenue
Purpose
Trending indicator of propensity to

convert net revenue to cash
Value
Indicates fiscal integrity / financial

health of the organization
Total Cash Collected
Average Monthly Net Revenue
Calculation
71

MAP Keys: Bad Debt (%)

Indicator
Purpose
Value
Calculation
Bad Debt
Trending indicator of the effectiveness
of self-pay collection efforts and
financial counseling
Indicates organizations ability to
collect self-pay accounts and
identify payor sources for patients
unable to meet financial obligations
Bad Debt Write-Off
Gross Patient Service Revenue
72
MAP Keys: Charity Care (%)

Indicator
Charity Care
Purpose
Trending indicator of local ability to

pay
Value
Indicates organizations ability to

collect self-pay accounts and
identify payor sources for patients
unable to meet financial obligations
Calculation
Charity Care Write-Off

Gross Patient Service Revenue
73
MAP Keys: Days in Total DNFB
Indicator
Days in Total Discharged Not Final

Billed
Purpose
Value
Trending indicator of local ability to

pay
Indicates RC performance and can
identify performance issues
impacting cash flow
Calculation
Gross Dollars in DNFB A/R

Average Daily Gross Revenue
74
MAP Keys: Aged A/R Percentage of Billed A/R by Payor
Indicator
Purpose
Aged A/R as a % of Billed A/R, by

Payor Group
Trending indicator of receivables
collectability, by payor group
Value
Indicates RCs ability to liquidate A/R,

by specific payor group
Calculation
Billed Payor Group by Aging

(>30,>60,>90,>120 days)
Total Billed A/R by payor group
75

MAP Keys: Days in FBNS

Indicator
Days in Final Billed Not Submitted to

Payor (FBNS)
Purpose
Trending indicator of claims delayed

by payor / regulatory edits in the
claims processing system
Value
Track the impact of internal / external

requirements for clean claim
production, which impact cash flow
Calculation
Gross Dollars in FBNS

76
MAP Keys: Days in DNSP (DNFB + FBNS)
Indicator
Days in Total Discharged Not

Submitted to Payer (DNSP)
Purpose
Trending indicator of total claimsgeneration / submission effectiveness
Value
Indicates revenue cycle performance

and can identify performance issues
impacting cash flow
Calculation
Gross $ in DNFB + Gross $ in FBNS

77
MAP Keys: Late Charge Percentage

Indicator
Purpose
Value
Calculation
Late Charges as % of Total Charges

Measure of revenue-integrity
effectiveness
Identify 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 date
Total gross charges
78
MAP Keys: Initial Zero-Pay Denial Rate (#)

Indicator
Initial Denial Rate Zero-Pay Claims
Purpose
Trending indicator of percentage of

claims not paid
Value
Indicates providers ability to comply

with payor requirements and payors
ability to accurately pay claims
Calculation
Number of zero-pay claims denied

Number of total claims remitted
79
MAP Keys: Initial Partial-Pay Denial Rate (#)

Indicator
Initial Denial Rate Partial-Pay Claims
Purpose
Trending indicator of percentage of

claims partially paid (underpaid)
Value
Indicates providers ability to comply

with payor requirements and payors
ability to accurately pay claims
Calculation
Number of partial-pay claims denied

Number of total claims remitted
80
MAP Keys: Appeals Success Rate (#)

Indicator
Denials Overturned on Appeal
Purpose
Trending indicator of providers success

in managing the appeal process
Value
Indicates opportunities for payor and

provider process improvement and
cash-flow improvements
Calculation
Number of appealed claims paid

Total number of claims appealed and
finalized or closed
81
MAP Keys: Net Days in A/R Credits
Indicator
Purpose
Value
Calculation
Net Days Revenue in Credit Balances

Trending 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 Balances
Average Daily Net Patient-Service
Revenue
82
MAP Keys: Pre-Registration Rate

Indicator
Pre-Registration Rate
Purpose
Trending indicator of timeliness,

accuracy, and efficiency of patient
access processes
Value
Indicates revenue cycle efficiency and

effectiveness
Calculation
Number of patient encounters

pre-registered
Number of scheduled patient
encounters
83
MAP Keys: Insurance Verification Rate

Indicator
Insurance Verification Rate
Purpose

access processes
Value
Indicates revenue cycle process

efficiency and effectiveness
Calculation
Total number of verified encounters

Total number of registered encounters
84
MAP Keys: Service-Authorization Rate

Indicator
Service-Authorization Rate
Purpose

access processes
Value
Indicates revenue cycle process

efficiency and effectiveness
Calculation
Number of encounters authorized

Number of encounters requiring
authorization
85
Lets get down to details
86
Scheduling
Pre-Registration / Pre-Authorization
Insurance Verification
Patient Access / Registration
Health Information Management
Charge Entry / Revenue Protection
87
Billing / Claim Submission

3rd-Party and Guarantor Follow-Up
Cashiering / Refunds / Adj Posting
Denials
Customer Service
Collection / Outsourcing Vendors
Physician Practice Management
Managed Care Contracting
88

Scheduling
KPI Description
1. Overall scheduling rate of potentially-eligible patients:
Standard
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%
89

Scheduling
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
90

Scheduling
KPI Description
Process
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
91
KPI Description
Standard
1. 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%
92

KPI Description
Process
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
Yes
Yes
93

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%
99%
94

KPI Description
Process
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
Yes
Yes
95

KPI Description
Standard
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
99%
7. ABNs / MSPQs obtained when required
100%
8. MPI duplicates created daily as a % of total registrations
1%
96

KPI Description
Process
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
97

KPI Description
Process
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
98

KPI Description
Standard
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%
99

KPI Description
Process
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
100

KPI Description
Process
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
101

KPI Description
Standard
1. 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
7. Total chart delinquency
5%
10%
102

KPI Description
8. HIM DRG development hold greater than late charge hold
9. Copies of medical records pursuant to payors requests
10. Transcription rate per line
Standard
2 A/R days
2 work days
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%
Program for Evaluation Payment Patterns Electronic Report
103

KPI Description
Process
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
104

KPI Description
Process
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
105

KPI Description
Process
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
106

KPI Description
Process
22. Review PEPPER to compare MCR pmts w/ state & natl 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
107
Charge Entry / Revenue Integrity

KPI Description
1. Late charge hold period
Standard
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
5. CDM incorrect / missing HCPCS / CPT-4 codes
6. CDM incorrect / invalid revenue codes
7. CDM revenue code lacks necessary HCPCS / CPT-4 code
108

KPI Description
Standard
8. CDM item has invalid / incorrect modifier
9. CDM item has missing modifier
10. CDM item price less than HOPPS APC rate
11. CDM item price is $0
12. CDM item description is Miscellaneous
13. CDM item description / price is editable on-line
109

KPI Description
Process
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
110

KPI Description
Process
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
111

KPI Description
Process
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
112

KPI Description
Process
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
113

KPI Description
1. HIPAA-compliant electronic claim submission rate
2. Final-billed / claim not submitted backlog
Standard
100%
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

6. Outsourced guar stmt cost to produce / mail (w/out stamp)
3%
20 - 25
114

KPI Description
Process
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 CMSs Medicare billing training?
Yes
6. All billers receive annual Medicare compliance training?
Yes
7. Billers cross-trained on more than one payor type?
Yes
115

KPI Description
8. Use on-line electronic billing system?
Process
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
116

KPI Description
Process
8. Use on-line electronic billing system (cont)?
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
117

KPI Description
Process
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
118

KPI Description
1. Ins A/R aged more than 90 days from service / discharge
Standard
15 - 20%
5%
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%
119

KPI Description
8. In-House A/R days
9. D-N-F-B A/R days
10. Net A/R days
11. A/R cash as a % of cash goal
12. Total point-of-service cash as a % of cash goal
Standard
ALOS
4 6 A/R days
50 A/R days
100%
2 - 3%
120

KPI Description
Process
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 CMSs Medicare billing module?
Yes
6. All collectors receive annual Medicare compliance training?
Yes
7. Collectors cross-trained on more than one payor type?
Yes
121

KPI Description
8. Use on-line receivables work station system?
Process
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
122

KPI Description
Process
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
123
Cashiering / Refunds / Adjustment Posting

KPI Description
Standard
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)

5. Medicare credit-balance report submission timeliness
2 A/R days
due date
124

KPI Description
Process
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
125

KPI Description
Process
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
126

Denials / Underpayments
KPI Description
Standard
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

5. Appealed denials overturned rate
75%
40 60%
127

KPI Description
Standard
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
128

KPI Description
Process
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
129

KPI Description
Process
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
130

KPI Description
Process
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
131

Customer Service
KPI Description
1. Correspondence backlog
Standard
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

8. Calls resolved in unit, w/out complaint / referral to Dir PFS
5%
95%
132

Customer Service
KPI Description
Process
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
133

Customer Service
KPI Description
Process
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
134

KPI Description
1. Bad debt netback ([collections fees] placements) %
2. Bad debt fee %
3. 3rd-party EBO (Extended Bus Ofc) fee % (IP + OP + ER blend)
Standard
7 11%
15 18%
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%
135

KPI Description
Process
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
136

KPI Description
Process
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
137

KPI Description
1. Visits w/out charges as % of total visits
Standard
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

5. Claims passing claim edits as % of total claims
6. Appointment no-show rate
1 bus day
98%
2 - 3%
138

KPI Description
7. Appointment bumped rate
8. Net A/R days (non-specialty practices)
9. Collections as % of net revenue
Standard
2 - 3%
40 days
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%
139

KPI Description
13. Claims w/ no activity > 90 days from last activity date
Standard
0%
14. Credit balances
2 A/R days
15. Average patient wait time after office arrival
15 minutes
140

KPI Description
Process
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
141

KPI Description
Process
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
142
Lets pause and define terms...

Contracting Cycle
143

Contracting Cycle Definition
1. Provide
patients
2. Treat
patients
4. Pay
claims
3. Submit
claims
144

Reduce Payor Discretion
Achieve Target Margins

145

Analyze
Contract
Performance
Collect Accounts &
Post Payments
Analyze
Service
Lines
Analyze
Financial
Needs
Understand
Competitors
& Market
Work Denials &

Payment Variances
Submit &
Follow-up
Claims
Understand Payors &

Their Reputations
Define Payors &

Providers Duties
Negotiate Contract
Language & Rates
Analyze
Steerage vs.
Discounts
146

Strategy development
Strategy implementation
Contract negotiations
Contract evaluation
Forecasting and analysis
Contract implementation and operations
Performance monitoring
Strategic issues and planning
SOURCE: Stevenson, Managed Care Cycle Provides Contract Oversight, hfm
147

KPI Description
1. Rate increases compared to CPI medical-care component
2. Outlier $ fraction of total contract revenue
3. Contract profitability compared to IRR hurdle rate
4. Eligibility / authorization / certification availability
5. Retro review / timely filing periods (keep in balance)
6. Termination notification period (without cause)
7. Renegotiation planning begins prior to renewal date
8. Optimal contract term
Standard
CPI MCC
5%
IRR HR
24 / 7 / 365
90 120 days
90 days
6 months
2 3 years
148

KPI Description
Process
1. 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?
Yes
7. Provider authorized to bill guarantor for non-covered svcs?
Yes
8. Hospital-based MDs use hospital-obtained authorizations?
Yes
SOURCE: Managed Care Forum Contracting Checklist, HFMA Wants You to Know
149

KPI Description
Process
9. 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
150

KPI Description
Process
15. Definition / criteria for all key terms clearly stipulated (cont)?
Yes
Trauma / trauma services / trauma team?
Yes
Covered services?
Yes
Material breach?
Yes
Prompt payment?
Yes
Stop-loss / outlier?
Yes
Carve-out?
Yes
Medicare rate? (should include pass-throughs)
Yes
151

KPI Description
Process
Yes
Sentinel event(s)?
Yes
Medical-loss ratio?
Yes
Silent PPO?
Yes
Clean claim?
Yes
Timely notification / timely filing?
Yes
Authorization / certification?
Yes
152

KPI Description
Process
Yes
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
153

KPI Description
Process
16. Advance notice time for contract changes clearly stipulated?
Yes
Payment / reimbursement rates?
Yes
Covered 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. Payors reporting requirement duties clearly stipulated?
Yes
154

KPI Description
Process
20. Contract clearly material to providers revenue stream?
Yes
21. Eligibility verification process clearly stipulated?
Yes
22. 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
155

KPI Description
Process
28. Payors prompt payment duty clearly stipulated?
Yes
29. Payor agrees to pay interest on late payments?
Yes
30. 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
156

KPI Description
Process
36. Perform annual internal analysis of all contracts?
Yes
Contractual discounts balanced to gross volumes / net rev?
Yes
Use 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
157

KPI Description
Process
37. Perform annual external analysis of all contracts?
Yes
Compare (legally) your rates to those of similar providers?
Yes
Use outside firms / databases to obtain comparative info?
Yes
Challenge datas 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
158

KPI Description
Process
37. Perform annual external analysis of all contracts (cont)?
Yes
Review contract language, especially key terms / clauses?
Yes
Claim 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
159

KPI Description
Process
37. Perform annual external analysis of all contracts (cont)?
Yes
Compare payment levels to premium increases?
Yes
Ensure rate trends mirror premium increase trends?
Yes
Compare payors relative profitability trends?
Yes
Compare rate trends to medical-care component of CPI?
Yes
160

KPI Description
Process
38. Conduct annual pmt performance analysis of all contracts?
Yes
Contracts comply with statutory processing / pmt regs?
Yes
Report 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
161

KPI Description
Process
39. Contract defines documentation reqd to prove timely filing?
Yes
40. Contract reviewed by attorney before renewal?
Yes
41. 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
162

KPI Description
Process
48. Start up payors post security deposit / letter of credit / etc?
Yes
49. Contract parties independent and able to compete?
Yes
50. Provider listed as participating in directories / websites?
Yes
51. 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

163

KPI Description
54. Services not directly provided defined / contracted in adv?
Process
Yes
Out-of-area services
Yes
Hospital-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

164

KPI Description
61. Mutual information requirements clearly stipulated?
Process
Yes
Specific information / reports described?
Yes
Information including but not limited to avoided?
Yes
Providers confidential / proprietary information protected?
Yes
Providers duty to provide info to payor strictly limited?
Yes
Payor obligated to reimburse costs of providing records?
Yes

165

KPI Description
Process
62. Mutual duties regarding care reviews clearly stipulated?
Yes
63. Providers 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

166
P4P: Clinical Decision Support / Finance

KPI Description
1. P4P Demonstration Project percentile ranking
2. P4P Demonstration Project bonus achievement
Standard
80%
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%
167
P4P: Clinical Decision Support / Finance

KPI Description
Process
1. 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
168

Accenture - Key Performance Indicators

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Accenture - Key Performance Indicators

Încărcat de

Drepturi de autor:

Formate disponibile

HFMA-Georgia Fall Institute

Savannah 09 November 2012

Key Performance Indicators (KPIs):

Content and Organization

Content and Organization (contd) Appendices

Even the VERY BEST Keep Score!

In business, words are

Even the VERY BEST Keep Score!

If you cant measure it,

Organization and Management

SOURCE: St. Vincent Health System, Indianapolis

Organization and Management

SOURCE: PriceWaterhouse Coopers

What is HFMAs MAP initiative?

HFMAs MAP Initiative

HFMAs MAP Initiative

Share successful practices

HFMAs MAP Initiative

MAP Keys are provider-developed

HFMAs MAP Initiative

MAP Keys focus on key areas of

HFMAs MAP Initiative

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

HFMAs MAP Initiative

Indentify successful practices

HFMAs MAP Initiative

Pre-selected peer groups

Bad Debt vs Charity Care as % of Revenue

What is HFMAs MAP Award?

HFMAs MAP Award

Revenue Cycle Excellence

HFMAs MAP Award recognizes healthcare

HFMAs MAP Award

MAP Application Data Approach

The MAP application evaluates HFMAs

HFMAs MAP Award

Sample Insights from High-Performance Organizations

Improvement Opportunity: POS Collections

% of high performers that cite importance

Top-25 quartile: 35%

Source: HFMAs 2010 MAP Award Data

POS Collections Comparable Statistics

% of high performers offering price

Use of sample scripts

Use of dedicated Patient Access trainers

How should you measure performance?

Key Performance Indicators

Performance Measurement Concepts

Key Performance Indicators

Performance Measurement Concepts

Report both good and bad results

Not all KPIs are created equal

Key Performance Indicators

Level I: Board members, senior execs, financial and

Key Performance Indicators

Level III: CFO plus internal reporting for all revenue

Key Performance Indicators

KPI Hierarchy First-Level Indicators

Key Performance Indicators

Key Performance Indicators