Medical Revenue Cycle Management Metrics

Medical Revenue Cycle Management Metrics guide 2020 – explanation of HFMA MAP keys. Read this guide to maximize your practice’s revenues using a RCM team approach.

Medical Revenue Cycle Management Metrics guide for 2020. Read this guide if you have transitioned your thoughts from “medical billing” to revenue cycle management. To maximize your practice’s revenues, you need to start thinking of medical billing as a team effort. Read this guide for understanding revenue cycle management processes first (if needed).

Why is revenue cycle management important in healthcare?

As you can understand from the previous guide, the revenue cycle is truly a “cycle”. Each step feeds the other and the success, efficiency of each step depends on other steps of the revenue cycle. 

There is no one that does this perfectly. MGMA typically has KPIs and guidance around RCM performance. We use the same with our clients.

You can also follow the same guidelines as MGMA and HFMA suggests. MGMA actually announces “MGMA better performers” each year as well.

If you incorporate revenue cycle management processes as part of your overall business strategy, this is almost guaranteed to improve reimbursements, accurate billing, compliance and more often than not, greater clinical outcomes.

What is KPI in medical billing?

KPIs are Key Performance Indicators (KPIs). That’s about it – buzzwords.

KPIs help you, the physician leader or you, the practice management staff understand your revenue cycle’s strengths and weaknesses.

As you are well aware of, unless you measure something, you cannot improve that “thing”.

KPIs in medical billing help you measure and help guide your future decisions.

Once you have medical billing or revenue cycle KPIs in place, you will be able to prioritize your staff, your resources and understand / identify the drivers for success and higher reimbursements.

How can hospitals increase their revenue cycle?

First and foremost – understand that revenue cycle management needs a front end AND a back end team. Have KPIs for both front end revenue cycle management and also for for the backend revenue cycle management team.

Employ software or technology to get a better (and easier) grasp of your performance data. Do not get into a situation where you cannot have the necessary decisions at the touch of a button. We have seen that when we ask most healthcare businesses for performance data, they scramble to print out reports from their practice management system and then divert their already busy staff to do analysis. Not only are their staff not qualified to do analysis, but this also usually affects other business processes that soon become overdue. Do not let this happen. Use technology to your advantage. Do not be scared of technology or data. 

There’s always going to be payer and patient financial responsibilities. Make sure that your front end revenue cycle management team collects patient financial responsibility upfront.

Try to automate prior authorizations and eligibility as much as possible. Not all of it is really possible and it depends from payer to payer, but even if you automate 30% of all your prior authorizations and eligibility checks, that’s better than zero.

As a side note – do NOT depend on the eligibility checks that most EPMs provide you. Dig a little bit deeper. We have found that many a time, a patient might be eligible, but their benefit does not pay for the CPT proposed by the provider.

Have a dedicated revenue cycle manager and a revenue cycle analyst on your team.

Why?

Because you need to analyze your revenue cycle management performance constantly. 

Based on the analysis, you need to make changes accordingly. Assisting the team to handle all the moving parts of the revenue cycle is a mature team leader /manager’s expertise. 

The manager’s expertise is to understand the data that is provided to them. More often than not, data analysis is not their expertise as this requires a completely different skillset.

Invest in these two roles and you will reap the rewards.

What does a revenue cycle manager do?

As mentioned above, your Revenue Cycle Manager will be the overall manager of your revenue cycle. This person will manage all functions of your organization’s billing and revenue cycle. They will be responsible to partner with your revenue cycle analyst and understand the data presented to them. 

They will be directly responsible for maximizing your healthcare organization’s cash flow.

The revenue cycle manager will also be responsible for maintaining and improving internal relations, interactions between the frontend and backend revenue cycle teams.

Your revenue cycle manager will also be responsible for external relations with patients and payers.

This is a senior position and requires having experience by having served in both the frontend and the backend revenue cycle teams.

What does a revenue cycle analyst do?

Your revenue cycle analyst is also a key team member.

Healthcare organizations are usually inundated with data. There’s payer related data, patient accounts related data, denials data, claims submissions data, and many more.

All these sources of information are brought together by your practice management system. 

However, data is just that – data. Unless you are getting actionable intelligence out of your revenue cycle analytics system, there’s really no point in gathering all that data.

Analysis of business data is a revenue cycle analyst’s job.

Healthcare data is almost always a moving target. Payers, payments, coverage, rules, regulations change all the time. This directly impacts the revenue cycle data and the associated analysis.

Your revenue cycle analyst is directly responsible for partnering with your revenue cycle manager.

The performance and success of your revenue cycle manager depends on the analytics and insights that the revenue cycle analyst provides them.

What is Revenue Cycle Analytics?

Revenue cycle analytics are just a way for you to monitor your revenue cycle processes’ performance, issues against the key process indicators that you have defined. More often than not, this is a dedicated technology solution that you purchase from your practice management system or a separate vendor.

Most practice management systems have decent revenue cycle analytics data but what they lack is actionable intelligence. They tell you the data – and that’s it. You need a few levels deeper than that. You need to know why those numbers look the way they do, where those numbers are originating from and finally, how to fix those issues.

Start with denials. That’s what you are trying to reduce the most and the first.

How do you reduce your denials?

You see the effects of the problems in your revenue cycle in the form of “denials”. But that’s the effect.

Get to the root cause of all those denials. 

Why are those denials happening? This is where data analytics starts to help you.

The first step is to analyze your denials data for the past 12-24-36 months. 

OK, so you can export the denials information from your practice management system. Then you run those via a google sheet or a spreadsheet (if you have a small amount of data). So, you run some pivot tables (if you are technically advanced enough) or run some denial data aggregation, grouping etc. 

You are finally able to categorize all those denials into buckets (groups). That is, only if you have a limited amount of data that a spreadsheet or google sheet can handle.

You are not going to be able to fix all of them in one shot, but you decide the easiest one first – preventable denials. 

Maybe you decide to fix the eligibility issues first.

So, your revenue cycle analyst tells your revenue cycle manager the information and the revenue cycle manager decides to get the team together to fix the eligibility issues in this quarter.

Great.

But, exported spreadsheets are stale the minute you export them.

Your billers fixed the eligibility issues and resubmitted the claims. They got paid. The minute they got paid, your initial analysis is now obsolete as those numbers have changed.

Hopefully, you put together a great workflow at the frontend revenue cycle team level that prevents these eligibility related issues moving forward.

How would you know whether your decision was correct?

How would you know that the frontend team is doing their job well?

The only way for you to understand this week after week is to run reports every single week. Isn’t it?

This is a moving target. Relying on spreadsheet data just gets you to analytics at a point of time. It is not real time, it doesn’t update itself all the time to provide you constant feedback.

What you need is daily feedback.

Top Revenue Cycle Key Performance Indicators – Nearterm

There are several key performance indicators to monitor in your revenue cycle.

However, it is also very easy to get overwhelmed with all the moving parts and all the KPIs.

Start small. Here are some top KPIs to start tracking today (even if you do nothing about them for now).

  1. Days in total – discharged not billed. This tells you about your charge lag from when the patient was seen vs when the claim was submitted. 
  2. Look at your clean claims rate. This will tell you the percent of claims submitted that are clean in the first pass itself (i.e. not denied). 
  3. Monitor your cash collections at the front desk. This will tell you if you are leaking revenues right at the front desk. This will also help you stay compliant with your payer contracts and MOUs.
  4. Track your total A/R and days in A/R. Most practice management systems will come with this information built-in.

Industry standard revenue cycle benchmarks

If you and your team are truly dedicated to being the best revenue cycle team, you will ultimately be looking for industry benchmarks and industry standard key performance indicators.

You can look at both MGMA and HFMA. We like both and you can glean really good information from both. Go ahead and become members of both please.

Keep in mind that HFMA is a membership organization for healthcare finance leaders. 

We like their KPIs and their goals – they help to maintain fiscally healthy healthcare organizations. 

Check out their certifications CHFP/CSBI/CSAF.

Meanwhile, MGMA is a professional association for medical practice administrators and executives. MGMA is also the source of medical practice economic data and data solutions. They have very resourceful DataDive content. Check out their certifications – CMPE /ACMPE

HFMA has something called MAP Keys.

We use the MAP Keys established by HFMA

“MAP Keys are industry-standard metrics or KPIs used to track your organization’s revenue cycle performance using objective, consistent calculations.”

From HFMA website

MAP keys are broken down into 5 main areas. There are (as of writing), a total of 29 MAP Keys.

  1. Account Resolution KPIs
  2. Financial Management KPIs
  3. Patient Access KPIs
  4. Pre-Billing KPIs
  5. Physician Financial Management KPIs

Let’s go into each. Do keep in mind that we tend to monitor a few more metrics on the marketing side as well.

Account Resolution KPIs

Accounts are patient accounts. As a services company (which you are), you have accounts that you service and get paid on.

One of the first things that most finance leaders look at after taking over an account’s billing (we do the same as well) is to look at the A/R.

What’s A/R? Simple – how many patient accounts have you billed for (submitted claims for) and are waiting to get paid on. 

If you have not posted charges (claim) for a patent account, you will not make that a part of the A/R. 

Why?

Because you cannot get paid for something that you have not billed for.. Yet. That remains in the bucket of “Discharged Not Billed”.

Aged A/R as a percentage of total billed A/R

Here, you are trying to measure your effectiveness in collecting A/R.

Your practice management system will typically show you aging buckets of 0-30, 31-60, 61-90, 91-120, > 120 days.

You will look at each bucket. But for this metric, you are looking at the total A/R as well (sum of all those buckets).

As an example, let’s say that the total A/R you are due to be paid is $10,000.

Out of ths $10,000, the breakdown might be:

A/R for 0-30 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 31-60 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 61-90 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 91-120 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for  > 120 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

Sum of all %s = 100%.

Points of Clarification:

Make sure you are adding ALL the aging buckets (0-30, 31-60, 61-90, 91-120, > 120 days) from the date of service or discharge.

Make sure that your aging buckets sum up to 100% (of course).

You are only including “active billed accounts” and not the ones where you have credit balance accounts. 

Do include recurring accounts that are open.

Make sure you include collectibles that are not classified as bad debt accounts yet (you might have outsourced these to a third party as well).

If you have “not final” accounts, do not include them – this includes anything your medical billing team has not yet billed to the payer or patient because these are NOT part of billed accounts receivables.

Make sure that you are adding up ALL A/R across ALL payers.

Trend analysis graph

Numbers are great but visuals help a LOT. E.g. see below

See the > 120 days bucket?

That’s a red flag.

Aged A/R as a percentage of billed A/R by Payer group

This is very similar to the above, but this shows you the trend analysis of the above data by payer in any reporting month.

This truly helps you to identify issues with specific payers. Some payers are good at reimbursements and some are not. You can identify the problematic payers and group them separately. You might want to assign a separate person or team to that specific payer. This team will start learning the tips and tricks of working with that payer and will guide the frontend revenue cycle management team (and you) better.

As an example, let’s say that your total A/R is $20,000.

Out of this, let’s say that Healthfirst and BCBS owe you $10K each. Does this give you enough actionable intelligence? Nope!

Let’s say that the total A/R you are due to be paid by Healthfirst is $10,000.

Out of ths $10,000, the breakdown might be:

A/R for 0-30 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 31-60 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 61-90 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 91-120 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for  > 120 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

Sum of all %s = 100%.

Let’s say the next payer is BCBS (Blue cross blue shield). They owe you $10,000 as well. However, their breakdown might be:

A/R for 0-30 days – $1,000. I.e. 10% of total A/R ($1,000/$10,000 = 10%)

A/R for 31-60 days – $2,000. I.e. 20% of total A/R ($2,000/$10,000 = 20%)

A/R for 61-90 days – $3,000. I.e. 20% of total A/R ($3,000/$10,000 = 30%)

A/R for 91-120 days – $1,000. I.e. 20% of total A/R ($1,000/$10,000 = 10%)

A/R for  > 120 days – $4,000. I.e. 20% of total A/R ($4,000/$10,000 = 40%)

Sum of all %s = 100%.

This kind of analysis tells you that there’s a problem in the >120 days aged bucket for BCBS that needs to be addressed asap because this is already very old and the chances of recovering the same are less.

Trend analysis graph

Numbers are great but visuals help a LOT. 

You should also view things by first vs last billed date. E.g.

Remittance denial rate

You NEED to know the % of claims being denied by your payers. This will surface MANY cracks in your medical practice’s compliance with payer requirements.

For any given month you are simply trying to find the rate of denial.

As an example, if your team submitted $10,000 in claims and got denied for $2,000 of those. Your denial rate for that month would be 20%.

Why do you want to plot it month over month? 

To see the trend. If it is trending down, your team is getting better at revenue cycle management. If your team swears that they have been fixing all preventable denials and the trend line is still going up, you realize that there is an issue on the payer’s side.

As an FYI, payers are not always correct. Their staff makes mistakes as well. 

Do keep that in mind.

To calculate this metric, follow this formula:

Total number of claims denied – this should be in your “Accounts Receivable”

Total number of claims remitted – this is really a sum of your 835 Files and/or Paper Remittance

Points of Clarification for this calculation:

Look at total claims adjudicated monthly at claim level. 

Make sure that you are defining “actionable denials”.

Why? Because your in-house or outsourced medical billing team can actually do something about it 🙂 That might end up in reimbursements!

Make sure you are only using those payments that have a denial code on the remittance advice.

Like we mentioned above – first and last submission dates. Take note of that and make sure you are including BOTH initial claim denials and subsequent appeal denial submissions.

You will notice many Zero payment accounts – include those.

You will also find claims that are partially paid. These accounts will typically contain a denial indicator. Include these as well.

Do NOT include denials where plans are denying due to non-covered services. There’s nothing “actionable” about it without fudging your claim.

Do not include Discharged Not Final Billed (DNFB) accounts.. I.e. where your medical billing department has not finalized the claim yet.

Do NOT include denials where the patient has the responsibility to pay.

Recovery Audit Contractor (RAC) recoupments should not be included either. BTW, Do you know how to review your Medicare remittance advice ?

Duplicate claims should not be included either.

“Shadow claims”, or “no pay” or “information only” claims that your billing department might have done/submitted.

For the total Number of Claims Remitted – your EPM will give you this. You can also look at all the 835 data submitted (or paper). Keep in mind that you are NOT including line items. Each claim has several line items. You need to include claims as a line item for this metric calculation.

Trend analysis graph

Numbers are great but visuals help a LOT. E.g. see below

Financial management KPIs

As per HFMA, there are only 2 KPIs in this. 

Net days in A/R and Cash collections as a percentage of Net Patient Service Revenue

These two are pretty simple to handle as well and give you a better handle of your cash performance.

Net days in accounts receivable A/R

You need to know your days in AR stone cold. At any point, you should be able to tell your net days in AR trends.

How to calculate days in A/R (account receivables)

You wait to get paid from the payers and your patients. The faster you get paid, the better it is for you (of course).

Whether you outsource your medical billing or have inhouse medical billers, always know your days in AR. This shows you how well your billing operations are doing (i.e their efficiency).

Here’s how you calculate it.

Total A/R year to date divided by the total billing (not collections) per day.

First, calculate your “Total Accounts Receivable”. 

If you have been following this article, you already did it above.

If you use a blended model of in-house and outsourced billing, add both of these amounts.

If you get any CAH (critical access hospital) payments- add those up.

Add up all your Insurance balances + Patient balances. 

From this, deduct any Credit Balances and Collection Agency Accounts.

Next, deduct any charitable amounts. Remove any contractual allowances from any payers that you might have.

Next, take your 12 months of charges (gross charges) and divide it by 365 (days). This gives you your average daily billing / Average Daily Net Patient Service Revenue.

Finally, divide the “Total accounts receivable” by this number.

So,

 “Total Accounts Receivable”. Add up all your Insurance balances + Patient balances. From this, deduct any Credit Balances and Collection Agency Accounts

— divided by —

12 months of charges (gross charges) and divide it by 365 (days)

How did you do?

Net days in A/R – industry benchmarks

If your days in AR is < 35 – that’s GREAT

Days in AR between 35-50 days – you are around the industry average

If your days in AR is more than 50 days – this truly is a RED FLAG and you need to address this immediately.

Keep in mind that this also depends on the specialty we are talking about and the payer mix as well.

You should calculate this per payer as well, to identify problematic payers. There might be an issue with the payer in question. There might also be an issue with your billing department with regards to that particular payer (some process might be missing or misunderstood).

Sometimes you really do not have a choice of payers you want to work with (e.g. in NYC, how do you avoid HealthFirst).

Other times, you can drop a payer from your accepted insurances if you find that they are problematic payers. Or, at the very minimum, bring this up to that payer’s provider relationship manager.

Points of Clarification:

Do keep in mind that should not include any A/R related to non-patient specific third-party settlements. Look out for any lump sum payments – we have encountered such lump sum payer payments in the past where a reconciliation project from the past was wrapped up in a year that we were working on those accounts.

If there are any Non-patient A/R, exclude those.

Keep in mind that if you’re an FQHC, 340B drug purchasing program revenue is NOT recognized as a patient receivable

You can’t include any state or county subsidies.

If you’re getting payments for capitation or getting risk based payments- don’t include those either.

You can’t include ambulance services payments.

For daily billing average / Average Daily Net Patient Service Revenue, you can also use the most recent three-month daily average of total net patient service revenue. 

Keep in mind to deduct contractual allowances, charity care provision, and any provision for doubtful accounts. 

Keep in mind that you cannot include 340B drug purchasing program revenue if your accounting department has not recognized this as a patient receivable. 

Also, keep in mind that you cannot include capitation and/or premium revenue related to value or risk based payer contracts

Cash collection as a percent of net patient service revenue

This is pretty simple. As you know that your net patient services revenue per month depends on both payers and patient responsibilities.

More often than not, the frontdesk (i.e. front end revenue cycle management team) is not the best at collecting from patients at the time of the patient’s visit.

All you have to do is to find out

  1. The total patient service cash collected.
  2. The average monthly net patient service revenue (you have already been calculating this as above)

Points of Clarification:

You need to deduct refunds from the total patient service cash collected for the reporting month

After collecting cash, there will be occasions where the payment is not distributed. You need to include those as well. 

However, you have to exclude non patient cash – e.g. retail pharmacy, optical, capitation etc.

For Average Monthly Net Patient Service Revenue, you can take the year to date calculation we provided above or do a 3 month average. Your choice.

Patient Access KPIs

As per HFMA, there are only 2 KPIs suggested here – both give you ample insights into your frontend revenue cycle management team performance.

  1. Percent of patient schedule occupied
  2. Point of sale cash collections

Percent of patient schedule occupied

Let’s say you have 10 providers that can see 30 patients per day. This means that you have 300 patient appointment slots available per day.

Now, let’s say that out of 300 such available slots, the total patient slots booked are 200 (underutilized) or 300 (exact)  or 400 (overbooking)

You are trying to calculate the utilization of those available patient slots (ie chargeable events). Measuring this metric will allow you to maximize utilization of your scheduled availability and hopefully, try to maximise capacity utilization.

The calculation is pretty simple – 

Number of patient slots occupied divided by number of patient slots available.

Point of service cash collections

Collecting payments from patients after they have left your clinic is hard. And it gets increasingly harder as days progress. You want to make sure you are collecting every penny that’s due from the patient, at the point of service, when the patient is right in front of you.

This alone will reduce your collection costs (following up, sending statements, chasing after patients etc).

Calculate the total patient payments made at your frontdesk and divide it by total self pay cash you have collected. 

According to HFMA, you can include cash collected up to seven days after the patient is discharged / seen as well. You can also include prepaid cash (e.g. you have a digital patient intake solution that allows patients to pay over the phone / mobile app).

What about payments on patient dues from past visits?

As per HFMA, if you are collecting it prior to this current visit or at the current visit, you can include this as well. However, for prior dues, you cannot include the payment if it is made after this visit.

You have to exclude any payment plan your collections team might have set up. You also have to exclude any cash your frontdesk might have refunded to the patient as well

To calculate the Total Self-Pay Cash Collected, you need to add all the cash collected for patient responsibility for the reporting month. This will include cash collected, all bad debts recovered, any loan payments as well.

Pre billing KPIs

HFMA has only one KPI for this – total charge lag days.
As mentioned before, you need to understand the charge lag days to find out the time spent between the patient being seen/discharged and when the charge is posted. 

This alone will tell you several things – including but not limited to whether your revenue cycle management team is adequately staffed or not. 

We will never advocate speeding up charge posting just to reduce the charge lag days. It is better to double check your work and take your time to post charges vs posting charges quickly and getting denials.

You pay the piper one way or another. Decide what you can live with.

Total charge lag days

For this, you need to calculate the total days from revenue recognition. You can recognize revenue when you post the charge. 

So, let’s say you billed 2000 charges in the reporting month and they were broken down like this.

There were 20 service dates in that month where 2,000 patients were seen.

Charges were posted:

  1. 400 charges were posted within 2 days of service date
  2. 500 charges were posted within 3 days of service date
  3. 300 charges were posted within 5 days of service date
  4. 500 charges were posted within 7 days of service date
  5. 300 charges were not posted in the month of reporting

So, the total charges posted were 1700 (not 2000).

The average is 400*2+500*3+300*5+500*7 / 1700 = 4.29 days

The industry benchmark is 3 to 5 days after date of service or post discharge; So, if you are anywhere close to that, you are doing OK.

Physician financial management KPIs

HFMA breaks this down into primary vs specialty care.

Primary and specialty care practice operating margin ratio

This is simply a calculation of the net income from your primary care practice operations divided by the primary care operating revenue. 

It helps you measure the financial performance of a PCP facility.

Net Income From Primary Care Practice Operations is what your PCP practice is making after paying all its expenses. Expenses include everything you need to operate. In other words, include marketing, supplies, salaries, insurance, real estate expenses, building, utility expenses.. All of it.

Meanwhile, Primary Care Practice Operating Revenue is all the revenues from seeing patients / from patient care services.

By calculating this, you are effectively trying to understand the operating margins

Net income per primary or specialty care FTE physician

Here, you are trying to understand the profit or loss per full time equivalent physician you have.

Each FTE physician you have, represents an investment – in terms of salaries, support staff, equipment etc. 

Calculating this metric will allow you to understand the profitability of your practice on a physician level. 

All you have to do is to calculate the net income from your practice operations and divide by the total FTE physicians you have.

Of course, practice expenses include all operating expenses as explained above.

Be careful when you calculate the total number of Primary Care Practice FTE Physicians. You are calculating a full time equivalent. So, if Dr Jones is getting paid for 20 hours per week – they are 20/40 = 0.5 FTE… not 1 FTE.

Total primary or speciality care physician compensation as a percent of practice operating revenues

Here, you are trying to understand the affordability of a physician compared to the revenues of the entire practice revenues.

Each physician contributes directly to the operating revenues of the healthcare practice. This gives you a measure of their compensation vs their direct contribution. 

To calculate this, you take the total physician compensation (include salary/bonus/benefits but exclude the insurance payments) and divide this by the Primary Care Practice Operating Revenue as you calculated above.

These are few of the metrics you need to start with to get a better grasp of your revenue cycle management team and processes. 

Once you start monitoring these, you will have the opportunity to dig into further items as well