Medical Reimbursement Unit 9 Discussion

MAP Category

Measure

Purpose

Value

Equation

Patient Access

N: POS Payments

D: Total patient cash collected

Patient Access

N: charity care write-off

D:Gross patient service revenue

Patient Access

N: Number of patient encounters preregistered

D: Number of scheduled patient encounters

Patient Access

N: Total number of verified

encounters

D: Total number of registered encounters

Patient Access

N: Number of patient encounters authorized

D: Number of encounters requiring authorization

Patient Access

N: Total inpatient cases approved

D:Total uninsured inpatient discharges

Days in Total Discharged Not Final Billed (DNFB)

Trending indicator of claims generation process

performance and can identify performance issues that impact cash flow

N: Gross dollars in accounts receivable (AIR) (not final bill)

D: Average daily gross revenue

Trending indicator of total claims generation and submission process

Indicates revenue cycle performance and can identify performance issues that impact cash flow

N: Gross dollars in DNFB + gross dollars in final billed submitted to prayer (FBNS)

D: Average daily gross revenue

Late Charges as % of Total Charges

Measure of revenue capture efficiency

Identify opportunities to improve revenue capture, reduce unnecessary cost, enhance compliance, and accelerate cash flow

N: charges with post date greater than three days from last service date

D: Total gross charges

Net Days Revenue in credit balance

Trending indicator to accurately report account values, ensure compliance with regulatory requirements and monitor overall payment’s system effectiveness

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

N: Dollars in credit balance

D: Average daily net patient services revenue

Revenue Integrity

Denial write offs as a percent of Net revenue

Trending indicator of final disposition of lost reimbursement, where all efforts of appeal have been exhausted or provider chooses to write off expected payment amount

Indicates provider’s ability to completely with payer requirement and payer’s ability to accurately pay the claim

N: Net dollars written off as denials

D: Net patient services revenue

Claims Adjudication

Aged A/R as a % of Billed A/R by Payer Group

Trending indicator of receivable collectability by payer group

Indicates revenue cycle’s ability to liquidate A/R by payer group

N: Billed payer group by aging (>30, >60, >90, >120 days)

D: Total billed A/R by payer group

Claims Adjudication

Days in FBNS

Trending indicator of claims impacted by payer/regulatory edits within claims processing system

Track the impact of internal/external requirements to clean claim production, which impacts positive cash flow

N: Gross dollars in FBNS

D: Average daily gross revenue

Claims Adjudication

Initial Denial Rate—Zero Pay

Trending indicator of % claims not paid

Indicates provider’s ability to comply with payer requirements and payer’s ability to accurately pay the claim

N: Number of zero paid claims denied

D: Number of total claims remitted

Claims Adjudication

Initial Denial Rate—Partial Pay

Trending indicator of % claims partially paid

Indicates provider’s ability to comply with payer requirements and payer’s ability to accurately pay the claim

N: Number of partially paid claims denied

D: Number of total claims remitted

Claims Adjudication

Denials Overturned by Appeal

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

Indicates opportunities for payer and provider process improvement and improves cash flow

N: Number of appealed claims paid

D: Total number of claims appealed finalized or closed

Claims Adjudication

UB04 (837I) Clean Claim Rate

Trending indicator of claims data as it impacts revenue cycle performance

Indicates quality of data collected and reported

N: Number of claims that pass edits requiring no manual intervention

D: Total claims accepted into claims scrubber tool for editing prior to submission

Management

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

Trending indicator of receivable collectability

Indicates revenue cycle’s ability to liquidate A/R

N: >30, >60, >90,>120 days

D: Total billed A/R

Management

Net Days in A/R

Trending indicator of overall A/R performance

Indicates revenue cycle efficiency

N: Net A/R

D: Average daily net patient service revenue

Management

Cost to Collect

Trending indicator of operational performance

Indicates the efficiency and productivity of revenue cycle (RC) process

N: Total RC Cost

D: Total cash collected

Management

Cash Collection as a Percentage of Adjusted Net Patient Services Revenue

Trending indicator of revenue cycle to convert net patient services revenue to cash

N: total cash collected

D: average monthly net revenue

Management

Bad Debt

Trending indicator of the effectiveness of self-pay collection efforts and financial counseling

Indicates organization’s ability to collect self-pay accounts and identify payer sources for those who cannot meet financial obligations

N: Bad debt write off

D: Gross patient service revenue

Management

Charity as a Percent of Uncompensated Care

Trending indicator that monitors charity care versus bad debt

Reflection of charity care (provided to the community)

N: charity care

D: total uncompensated care (bad debt + charity care)

Management

Case-Mix Index

Trending indicator of patient acuity, clinical documentation, and coding

Supports appropriate reimbursement for services performed and accurate clinical reporting

N: CMI (average RW per patient) = Sum of relative weight for all patients (exclusions: healthy newborns and Medicare-exempt units)

D: Number of patients in the month (exclusions: healthy newborns and Medicare-exempt units)

Management

Cost to Collect by Functional Area

Trending indicator of operational performance by functional area as reported in KI Cost to Collect

N: Total X (X – the cost of each functional area) cost, which should equal total cost of KPI cost to collect

D: Total cash collected

Source: Healthcare Financial Management Association. http://www.hfmamap.org .