Metrics for measuring healthcare revenue management

To make the claims process more efficient, and bring some ease to the most demanding aspect of practice revenue management, practices require insight into the health care supply chain. For years, athenahealth has been providing that type of insight by ranking insurance payers through the annual PayerView report.

PayerView is health care's leading annual quantitative payer report, providing an unprecedented view into the provider-payer relationship. It uses objective, data-driven methodologies to create a report that spurs industry dialogue about how to reduce unnecessary costs and optimize efficiencies within the revenue cycle.

Here are the metrics used to measure each health insurance payer in the 2013 PayerView report, as well as the way each metric illustrates how easy or difficult it is to work with a payer. Information like this brings transparency to the payment cycle, and can be useful for a practice’s revenue management:

• Days in accounts receivable (DAR) – How quickly, on average, a payer will process claims.
• First-pass resolve rate (FPR) – How often, on average, a payer will approve claims on initial submission.
• Provider collection burden – Percent of charges a payer transfers from the primary insurer to the next responsible party, including co-insurance, deductibles, and other transfers. This does not include co-pays and Real Time Adjudication (RTA) amounts, as this information is readily known at the time of service.
• Denial rate – Percent of claims (both pended and denied) that require practices to perform back-end rework.
• Enrollment Efficiency – The administrative burden a payer puts on practices to enroll for electronic transactions, including EDI, ERA, EFT and PAYTO.
• ERA (Electronic Remittance Advice) transparency – The percentage of electronic remittance advice (HIPAA 835) denial messages a payer provides that have actionable explanations and clear next steps; this shows how well a payer has adopted the HIPAA 835 standard code set by returning clear adjustment reason and remark codes.
• Eligibility Accuracy – How well a payer’s eligibility transaction predicts the outcome of your claims.
• Benefit Accuracy – Percentage of encounters in which a payer returns the accurate co-pay amount in response to claims.
• P4P Administrative Burden and Transparency – Indicates how easy or difficult a payer makes it for practices to get clear, useful information about enrolling in its incentive programs.