1. Best Practice for Patient Access

• Pre-Registration - (Excludes unscheduled visits such as emergency/urgent care cases)

  • Accurate completion of all patient data fields required for registration. --- 98%

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• Insurance Verification – (Includes non-scheduled encounters verified within one day of service or date of admission)

  • Scheduled encounters that have been verified prior to, or at time of service. --- 98%

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• Patient Collections - Collecting patient responsibility dollars for services rendered

  • Inpatient patient-pay balances prior to discharge --- > 65%

  • Outpatient patient-pay balances prior to service --- > 75%

  • ER patient-pay balances prior to departure --- > 50%

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• Financial Counseling - Payment arrangements made for individuals prior to rendering service

  • Screening of uninsured IPs & high balance OPs for financial aid --- 98%

  • Payment arrangements for non-charity eligible IPs and high balance OPs --- 98%

  • Prompt-payment discount percentages --- 5% - 20%
     

​2. Best Practice for Claim submission

Billing is one of the most crucial components in the healthcare business equation, requiring timely submission, corrections and consistent follow-up in order to receive timely payment for services rendered.

• HIPAA-compliant electronic claim submission rate --- 100%

• Discharged/Not Final-Billed (DNFB) backlog --- < 1 A/R Day

• Medicare Secondaries and supplements billed following adjudication --- < 2 Business Days

• Commercial COB billing following Primary payment --- < 2 Business Days

• Medicare RTP (Return to Provider) rate --- < 3%

 

3. Best Practice for Error Reduction
An estimated $262 billion (9%) of the roughly $3 trillion in claims submitted by hospitals last year were initially denied. Opportunity for error in the billing process is astronomical. Many people are involved in a single patient's bill; some sources estimate up to 55% of all patient bills contain errors which may result in denials and up to 1 in 4 claims are denied, according to research from the Government Accountability Office (GAO).

• Missing HCPCS or CPT-4 code --- 0 tolerance

• Missing or Invalid CPT/HCPCS codes --- 0 tolerance

• Missing/Invalid/Incorrect modifier --- 0 tolerance

• Incorrect Item pricing --- 0 tolerance

• Item description is “Miscellaneous” --- 0 tolerance

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​4. Best Practice for Denials Management
A vast majority of denied claims are recoverable (63%). However it still costs providers approximately $118 per claim on appeals, or as much as $8.6 billion in administrative costs nationwide. A typical health system can potentially lose as much as 3.3% of net patient revenue through denials.
Registration and Eligibility are cited as the leading causes of denials (23.9%) followed by Missing or Invalid Claim Data (14.6%). This combined 38.5% of denials are “Soft” denials, which can typically be paid upon correction. “Hard” denials (Non-Covered, Un-Timely Filing, etc.) must be written off.

• Overall initial denials rate (% of gross revenue) --- < 4%

• Clinical initial denials (i.e., Medical Necessity) rate (% of gross revenue) --- < 5%

• Technical denials (fulfillment of requests by payer) rate (% of gross revenue) --- < 3%

• Appealed denials overturned rate --- 40% to 60%

• Underpayments additional collection rate --- < 75%
   

5. Best Practice for Accounts Receivable
Cash is the lifeblood of any business and healthcare services are no different.

Maintaining a healthy accounts receivable (A/R) balance is essential to strong financial performance.

• Insurance A/R > 90 days from service or discharge (percent of total Ins A/R) --- < 15% to 20%

• Insurance A/R > 180 days from service or discharge (percent of total Ins A/R) --- < 5%

• Insurance A/R > 365 days from service or discharge (percent of total Ins A/R) --- < 2%

• Bad debt write offs (as a percentage of gross revenue) --- < 3%

• Charity write offs (as a percentage of gross revenue) --- < 3%

• Net A/R Days --- < 50

• Cost-to-Collect (as a percent of net patient revenue) --- < 3%
   

System reporting and analytics employed properly and consistently, are powerful tools in providing a comprehensive view of a hospital’s financial operations.

Contact Medical Recovery Services for a complete complementary list of Revenue Cycle Key Performance Indicators.