Claims First Pass Resolution Rate

Transcription

1 OpsDog KPI Reports Claims First Pass Resolution Rate Benchmarks, Definition & Measurement Details SAMPLE CONTENT & DATA 2017 Edition

2 Definition & Measurement Details What is Claims First Pass Resolution Rate? The total number of claims resolved on the initial submission (i.e., paid or transferred to patient responsibility) divided by the total number of claims adjudicated over the same period of time, as a percentage. Why should this KPI be measured? Claims First Pass Resolution Rate, or First Pass Resolve Rate, measures the percentage of claims paid or transferred to patient responsibility on initial submission to the insurance payer. Claims that are not resolved on the initial submission cause significant rework for both the health insurance payer and healthcare providers (e.g., doctors/practices, hospitals, healthcare systems, etc.). Poor inbound claims data (submitted by healthcare providers) is a common reason for claims rework. Missing claim information (e.g., no social security number, missing billing modifier, no plan code, etc.), duplicate claims submissions, and out-ofdate submissions (i.e., claim not filed within required timeframe) can all trigger claims denials, causing significant rework on both ends (i.e., for the insurance company and healthcare provider). A high amount of rework in the claims process drives costs up, reduces employee productivity and negatively impacts customer experience. How is this KPI calculated? Two numbers are used to calculate this KPI: (1) the number of medical insurance claims resolved on the first pass, and (2) the total number of medical claims adjudicated by the health insurance company over the same period of time. A medical claim resolved on the first pass should be considered any claim receiving a full or partial payment and/ or transferred to patient responsibility on the first initial claim submission ABRIDGED CONTENT (i.e., without need for subsequent data correction or resubmission). In the denominator for this calculation, do not include subsequent claims Purchase to View Full Definition & Measurement Details! submissions following the initial submission (e.g., if a claims must be submitted twice to correct an error with the initial submission, count that only once in the denominator). Related KPIs Claims Auto-Adjudication Rate, Claims Denial Rate (Medical/Health), Percentage of Claims Requiring Rework, Cost per Claim (Medical) Formula (Number of Medical Claims Resolved on Initial Submission / Total Number of Medical Claims Adjudicated) * 100 1

3 Benchmarks & Characteristics of High Performers Claims First Pass Resolution Rate (Number of Medical Claims Resolved on Initial Submission / Total Number of Medical Claims Adjudicated) * 100 High Performers SAMPLE CONTENT Low Performers Avg () Purchase to View Actual Benchmarking Data! Characteristics of High Performers KPIs are well-defined, tracked and tied to performance reviews Robust self-service options for customer (online FAQs, etc.) Agents cross-trained to handle and resolve multiple call types KPIs are well-defined, tracked and tied to agent performance reviews Sample Size: KPI Type: Unit: Is High or Low Best?: How to read this chart: This chart summarizes the performance gaps between high (Top 5%), mid (Median) and low (Bottom 5%) performers for this Key Performance Indicator (KPI). For example, the column labeled Top 5% represents a company that outperformed 95% of the peer group observed for this metric. 2

4 Benchmarks & Long Tail Analysis Claims First Pass Resolution Rate (Number of Medical Claims Resolved on Initial Submission / Total Number of Medical Claims Adjudicated) * 100 SAMPLE CONTENT Purchase to View Actual Benchmarking Data! Avg () Min Top 25% Cut-off Median Bottom 25% Cut-off Max High Performers Low Performers How to read this chart: This chart plots all values within the observed population for this KPI. This chart can be useful in analyzing the upper and lower boundaries (i.e., minimum/maximum values) and the amount of the population that falls above/below the average for the KPI, among other things. 3

5 Benchmarking Report Terms & Conditions OpsDog KPI Reports 2017 OpsDog, Inc. The OpsDog KPI Reports and their contents are protected by copyright laws, contain the trademark OpsDog, Inc., and are OpsDog s proprietary information. No part of this book shall be reproduced, stored in a retrieval system, or transmitted by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from OpsDog, Inc. OpsDog, Inc. assumes no liability with respect to the use of the information contained herein which is provided as is and there are no warranties of any kind provided by OpsDog with respect to this report. OpsDog assumes no responsibility for errors or omissions and will not be liable for any damages resulting from the use of the information contained herein. OpsDog, Inc Augusta Dr., Suite 200 Houston, TX Tel: