Our seasoned revenue cycle management professionals have chosen the 20 most influential KPIs for medical providers, including the RCM process from patient scheduling to payment. The KPIs are organized by billing phase and supplemented by our internal benchmarks or the relevant industry standard.
The Top 20 Healthcare RCM KPIs
The advantages of effective revenue cycle management cannot be emphasized. However, with over a hundred indicators to monitor the health of their RCM, it can be difficult. Knowing the proper KPIs – the most important to the business — can save you time and effort, allowing you to concentrate on generating business outcomes.
Discover a comprehensive list of essential KPIs, from Days in Accounts Receivable (AR) to First Pass Acceptance Rate. Gain insights into each metric's role and significance in maintaining a healthy revenue cycle.
1. No-show or cancellation rate
The no-show or cancellation rate is when your patients cancel or don't attend appointments, typically measured monthly. The formula to calculate the no-show rate is:
No-show rate = Missed appointments / Total number of booked appointments
2. Exclusion Percentage
Exclusions are the patient accounts that failed the eligibility and benefits checks (that don't have active insurance coverage), were unable to get the active insurance details, had coverage terminated claims, or had incomplete demographics while verifying the status. The formula to calculate the exclusion percentage is as follows:
Exclusion percentage = Number of accounts that failed eligibility checks / Total number of accounts verified
3. Denials Due to Authorization Percentage
Prior authorization is critical when you have to render a service and ensure that claims are paid. The denial due to incorrect or no authorization percentage is a critical metric to ensure collections and reduce claim write-offs. The formula to calculate the denial percentage due to authorization is:
Denial due to authorization percentage = Value of claim denied for authorization issues / Total value of denials
4. Unbilled Claims Percentage
Unbilled claims percentage refers to claims not billed to average daily claims volume. There are many reasons for the hold claims, but they should be resolved promptly for faster payments or denied for a timely filing limit. The formula to calculate the percentage of the unbilled claim is as follows:
Unbilled claims percentage = Number of claims unbilled / Average daily claims volume
5. Clean Claim Ratio
The clean claim ratio is the percentage of claims the insurance payer accepts without rejection.
Clean claim ratio = Number of claims accepted by insurance without changes / Total number of claims
6. Initial Denial Percentage
The initial denial is the number of denials received from the overall claims submitted to the insurance, expressed as a percentage. The formula to calculate the initial denial percentage is:
Initial denial percentage = Number of denials received for the first time / Total number of claims submitted
Strategies for Improvement
Equip yourself with practical strategies for improving key metrics. Learn how to address common challenges and elevate your organization's financial health.
Conclusion:
Wrap up your journey through the intricacies of Healthcare Revenue Cycle Management armed with the knowledge to optimize performance, boost efficiency, and confidently navigate the complexities of healthcare finance. Ready to revolutionize your approach to RCM? Dive into our latest blog post for a transformative exploration of Revenue Cycle Management KPIs
