Accenture - Key Performance Indicators

8/17/2019 Accenture - Key Performance Indicators

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HFMA-Georgia – Fall InstituteSavannah – 09 November 2012

Key Performance Indicators (KPIs):Strategies for a High-Performance

Revenue Cycle

David Hammer, FHFMA

Senior Vice President – Revenue Cycle Advisory SolutionsMedAssets – Alpharetta, GA


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Content and Organization

Introduction

Key Performance Indicators

HFMA’s MAP


Performance Measurement Concepts KPI Hierarchy

Level I, II, III, and IV KPIs

Case Study

Metric-Driven Revenue Cycle


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Definitions of HFMA’s MAP Keys

KPIs by Functional Area

Best Practice Performance Standards

Best Practice Processes

Call to Action

Content and Organization (cont’d) – Appendices


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Even the VERY BEST Keep Score!

“In business, words arewords, explanations are

explanations, promises arepromises, but only performance is reality .”

Harold S. Geneen

Former President and CEO of ITT


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“If you can’t measure it,you can’t manage it .”

Michael Bloomberg

Mayor of New York City and

CEO of Bloomberg, Inc.

Even the VERY BEST Keep Score!


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Pricing

Registration

Financial Counseling

Billing

Follow-up

CashPosting

Denials &Discrepancies

Collection

Compliance

Coding

Contracting

Organization and ManagementStructure and Function

SOURCE: St. Vincent Health System, Indianapolis


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RACs&

MICs

CapitalMarkets

Affiliated &Employed MDs

Employers

HMOs /PPOs

O.I.G & OtherRegulators

Financial Institutions

Medicare &Medicaid FIs

HEALTHCAREREFORM

COMPLIANCE

PATIENT

CASH FLOW

COSTCONTAINMENT

CONSOLIDATION /STANDARDIZATION

QUALITY-DRIVENREIMBURSEMENT

SOURCE: PriceWaterhouse Coopers 6

Organization and ManagementStructure and Function

DENIAL &

APPEALMANAGEMENT

SCHEDULING

1PRE-REG &PRE-CERT

2

INSURANCEVERIFICATION

3

FINANCIALCOUNSELING

4

REGISTRATION & POS CASHCOLLECTIONS

5

CHARGECAPTURE& ENTRY

6MEDICAL

MANAGEMENT

7

CLAIMSSUBMISSION

9

THIRD PARTYFOLLOW-UP

10

PAYMENTPOSTING

11

13

CONTRACTNEGOTIATION /

ADMIN.

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REJECTIONPROCESSING

12

MEDICALRECORDS &

CODING

8

Revenue

Information Technology


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What is HFMA’s MAP initiative?


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HFMA’s MAP Initiative Revenue Cycle Excellence


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MAP is a comprehensiveperformance-improvement strategy

Identify indicators

Track and improve performance

Recognize excellence

Share successful practices

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HFMA’s MAP Initiative What is MAP?


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Clearly-defined

Measurable

Discerning

Comparable

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HFMA’s MAP Initiative What are MAP Keys?

MAP Keys are provider-developedrevenue cycle key performance indicators


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Patient Access

Revenue Integrity

Claims Adjudication

Management

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HFMA’s MAP Initiative MAP Keys

MAP Keys focus on key areas ofrevenue cycle performance


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Indicator

PurposeValue

Calculation

Net days in A/R

Trending indicator of overall A/R performanceIndicates revenue cycle efficiency

Net A/R÷ Net patient-service revenue

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Purpose | Value | CalculationExample


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Manage trends

Identify opportunities

Prioritize opportunities

Indentify successful practices

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Comparing Performance


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Industry trends

Performance over multipletime frames

Pre-selected peer groups

Customized peer groups

Source: HFMA’s

Bad Debt vs Charity Care as % of Revenue

Jan 09 Mar 09 May 09 Jul 09 Sep 09 Nov 09

0%

1%

3%

4%

5%

14


Comparing Performance:Flexible comparisons for in-depth analysis


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What is HFMA’s MAP Award?


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HFMA’s MAP Award recognizes healthcareorganizations that achieve revenue cycleexcellence and serve as models for the

healthcare industry

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HFMA’s MAP Award Revenue Cycle Excellence


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HFMA’s MAP Keys (KPIs) are the primary metricsused in the application

Best practices identified in 2009’s PFB® researchare incorporated in the MAP Award application

Additional criteria to evaluate patient satisfactionare also included

The MAP application evaluates HFMA’sfinancial-performance MAP Keys, as well as

PATIENT FRIENDLY BILLING ® Project criteria

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HFMA’s MAP Award MAP Application Data Approach


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Point-of-Service CollectionsTop-25 quartile: 35%

Top-10 decile: 46%

Research% of high performers that cite importance

of investing in upstream technologies

% of high performers offering priceestimates to patients at registration

Successful practicesUse of sample scripts

Use of dedicated Patient Access trainers

Source: HFMA’s 2010 MAP Award Data

Source: HFMA’s March 2010

POS Collections Comparable Statistics27% Median

43.6% Top-Quartile Performance

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HFMA’s MAP Award Sample Insights from High-Performance Organizations

Improvement Opportunity: POS Collections


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How should you measure performance?


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Why Use KPIs? Keep a record and tell a story

Benchmark against your goals and industry bestpractices

Identify and manage trends, not single-periodresults

Illustrate relationships between KPIs

Key Performance IndicatorsPerformance Measurement Concepts


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Use external, verifiable info sources Share the same data with everyone

Board

Senior management

Peers

Subordinates

Report both “good” and “bad” results

Key Performance IndicatorsPerformance Measurement Concepts


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Not all KPIs are created equal…


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Level I: Board members, senior execs, financial andclinical directors, and internal reporting for all revenuecycle managers, supervisors, and employees

Level II: CFO, finance directors and employees, and

internal reporting for all revenue cycle managers,supervisors, and employees

Key Performance IndicatorsKPI Hierarchy


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Level III: CFO plus internal reporting for all revenuecycle managers, supervisors, and employees

Level IV: Internal comparisons of different payorsplus external reporting for third party payors

Key Performance IndicatorsKPI Hierarchy


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Key Performance IndicatorsKPI Hierarchy ─ First-Level Indicators

Cash collections

Gross and net A/R

In-House and D-N-F-B receivables

3rd

-party aging % > 90 days Cash % of net revenue

Cost to collect %


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Key Performance IndicatorsCash Collections ─ First Level


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Key Performance IndicatorsCash Collections ─ First Level

KPI GOAL M-T-D %

DAYS 20 10 50%

$ $20M $11M 55%


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Key Performance IndicatorsGross A/R ─ First Level


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Key Performance IndicatorsNet A/R ─ First Level


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Key Performance IndicatorsIn-House and D-N-F-B A/R ─ First Level


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Key Performance Indicators3rd-Party Aging % > 90 Days ─ First Level


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Key Performance IndicatorsCash % of Net Revenue ─ First Level


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Key Performance IndicatorsCost-to-Collect % ─ First Level


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Key Performance IndicatorsKPI Hierarchy ─ Second-Level Indicators

Net A/R days Allowance for doubtful accounts

Bad debt + charity % of gross revenue

Denials % of gross revenue

Cash % of collection goal

Point-of-service cash % of POS goal


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Key Performance IndicatorsNet A/R Days ─ Second Level


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Key Performance Indicators Allowance for Doubtful Accts ─ Second Level


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Key Performance IndicatorsB/D + Charity % of Gross Rev ─ Second Level


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Key Performance IndicatorsDenials % of Gross Revenue ─ Second Level


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Key Performance Indicators A/R Cash % of Cash Goal ─ Second Level


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Key Performance IndicatorsP-O-S Cash % of Goal ─ Second Level


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Key Performance IndicatorsKPI Hierarchy ─ Third-Level Indicators

Credit balance receivables

Clean claims throughput %

Collection agency netback %

Net revenue

Case mix index (CMI)

Complaints to Administration

Open accounts


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Key Performance IndicatorsCredit-Balance Receivables ─ Third Level


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Key Performance IndicatorsClean-Claim Throughput % ─ Third Level


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Key Performance IndicatorsCollection Agency Netback % ─ Third Level

f


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Key Performance IndicatorsNet Revenue ─ Third Level

K P f I di t


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Key Performance IndicatorsCase Mix Index (CMI) ─ Third Level

K P f I di t


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Key Performance IndicatorsComplaints to Administration ─ Third Level

K P f I di t


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Key Performance IndicatorsOpen Accounts ─ Third Level

K P f I di t


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Revenue Cycle KPI reporting sample for:Board of DirectorsFinance CommitteeFinance Division

Internal reporting System-wide reporting example MS Access database Managed Care “Report Cards” (letters, actually…)

Key Performance IndicatorsManaged Care Report Cards ─ Fourth Level

K P f I di t


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By Major Payor Category or Plan Code % of Total A/R >60 Days

% of A/R >35 Days (No Pmt, No Response)

% of A/R in Underpaid Category

% of A/R in Appeal Status

% of A/R in Overpaid Category


K P f I di t


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MEASUREMENT PEER COMPARISONS SHOWTotal A/R by month Overall A/R trend & direction% A/R >60 days Claims processing issues

% A/R >35 days Promptness of payment%/$ Underpaid Contract interpretation issues%/$ Denials under appeal Denial issues%/$ Overpaid Contract interpretation issues


K P f I di t


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K P f I di t


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Ke Performance Indicators


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So… You think you want ametric-driven revenue cycle?



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Key Performance IndicatorsPlanning and Implementing – Key Thoughts

How do you start?Open the discussion

Take time to define / refine KPIs

Gain consensus and commitment

How do you use KPIs to enact change?

Understand processes that generate KPIs

Create a culture of accountability and reward

Continuously adapt and iterate



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Key Performance IndicatorsPlanning and Implementing – Key Thoughts

Take the complexity out; simplify your work View key indicators that provide early warnings

Maintain personal involvement in critical areas

Access a mix of early-warning and historical data



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Key Performance IndicatorsPlanning and Implementing – Key Questions

Consider the following questions How do we enter data?

How do we get reports?

How do we use information to effect change?

When / why are things out-of-control?

What do we do?



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Open / frame the discussion 5% Define / refine KPIs 50%

Gain consensus / commitment 10%

Demand accountability / reward results 25%

Continuously adapt and iterate 10%

Achieve results! 100%

Key Performance IndicatorsPlanning and Implementing – Call to Action!

Where’s Your Focus?


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Where s Your Focus?

Bibliography


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Bibliography

1. “15 Questions to Ask Before Signing a Managed Care Contract,” Private

Sector Advocacy, Dec 20022. BearingPoint, Key Performance Indicators, Catholic Health East, 2003

3. Canfield, David and Scott Johnston, HFMA Patient Revenue CycleIndustry Study, © Healthcare Financial Management Association,Westchester, IL, 2002

4. “Clinical Quality Guidelines,” NEJM, 348:2635-45, June 26, 2003

5. Guyton, Elizabeth and Chuck Lund, “Transforming the Revenue Cycle,”Healthcare Financial Management, Mar 2003

6. Harris, David, “Turning Your Revenue Cycle Into a Hot Rod Using Bolt-On Technology,” HFMA ANI, Jun 2004

7. LaForge, Richard and Johnny Tureaud, “Revenue-Cycle Redesign:

Honing the Details,” Healthcare Financial Management, Jan 20038. “Managed Care Forum Contracting Checklist,” HFMA Wants You to

Know, 21 Apr 2004

Bibliography


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Bibliography

9. Miller, Thomas, “Conducting a Managed Care Contract Review,”Healthcare Financial Management, Jan 1998

10. Pogue, Neil – CMS Program Office, “Medicare Policy Update,” HFMA’sRevenue Cycle Strategies Conference, San Francisco, 09 Oct 2007

11. Schneider, Robert, Sheldon Mandelbaum, Ken Braboys, and CynthiaBailey, “Process-Centered Revenue Cycle Management OptimizesPayment Process,” Healthcare Financial Management, Jan 2001

12. Stevenson, Paul, “Managed Care Cycle Provides Contract Oversight,”Healthcare Financial Management, Mar 2002

13. Walters, Roy, “Five Steps to Great Revenue Cycle Management,”Healthcare Financial Management, May 2002

14. Wennberg, John, E. Fisher, T. Stukel and S. Sharp, “Use of MedicareClaims Data to Monitor Provider-Specific Performance Among Patientswith Severe Chronic Illness,” Journal of Health Affairs, 07 Oct 2004

15. Wilson, David, “3 Steps to Profitable Managed Care Contracts,”Healthcare Financial Management, May 2004

Instructor’s Bio


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David Hammer, Sr. VP – Rev Cycle Advisory Solutions, MedAssetsMr. Hammer is Senior Vice President of MedAssets’ Revenue Cycle Advisory SolutionsPractice, specializing in revenue cycle performance improvement, revenue integrity, andhealth reform. He serves many of the largest health systems, MD-led clinics, and academicmedical centers in the US. Prior to joining MedAssets, David was a Senior Executive with

Accenture. He has also served as VP of enterprise revenue management at McKesson, thenation's largest healthcare IT firm, and was previously the chief revenue officer for CharterBehavioral Health, a +100-facility health system. David has over 29 years of professionalexperience in healthcare, including executive leadership and direction, revenue cycletransformation, information system planning / implementation, and consulting. He hasworked for a variety of leading health systems, software vendors, and consulting firms.

Background and AffiliationsMr. Hammer received an MBA in Management and an MHS in Health Care Administrationfrom the University of Florida. He also received a BBA in Accounting with a minor in

Information Systems (Magna cum Laude) from the University of North Florida. Mr. Hammeris certified by HFMA as a Fellow (FHFMA) and as a Certified Healthcare FinanceProfessional (CHFP). He has been named an HFMA Distinguished Speaker for sevenconsecutive years, and is a 2007 recipient of HFMA’s Medal of Honor service award.

Recent PublicationsMr. Hammer’s most recent publication is “Health Reform: Intended and UnintendedConsequences,” which appeared in the October 2010 issue of HFMA’s healthcare financialmanagement journal (hfm). “Don’t Panic: CFOs React to the New Economic Reality,”appeared in hfm’s March 2009 issue. Mr. Hammer authored the February 2008 cover storyin hfm, entitled “Beyond Bolt-Ons – Breakthroughs in Revenue Cycle Information Systems.”

He also wrote the July 2007 cover story, called “The Next Generation of Revenue CycleManagement,” as well as the July 2005 hfm cover story, entitled “Performance is Reality: IsYour Revenue Cycle Holding Up?”

Contact InformationMr. Hammer can be reached by telephone at (954) 648-4764 and/or by e-mail [email protected] or at [email protected]

Instructor s Bio

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mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Appendices


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Definitions of HFMA’s MAP Keys…

HFMA’s MAP Initiative


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Indicator

Purpose

Value

Calculation

Net days in A/R

Trending indicator of overall A/Rperformance

Indicates revenue cycle efficiency

Net A/R

Average Daily Net PatientService Revenue

HFMA s MAP Initiative MAP Keys: Net Days in A/R

Purpose | Value | Calculation

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Indicator

Purpose

Value

Calculation

Aged A/R as a percentage of Billed A/R

Trending indicator of receivablescollectability

Indicates RC’s ability to liquidate A/R

>30,>60,>90,>120 days

Total Billed A/R


HFMA s MAP Initiative MAP Keys: Aged A/R Percentage of Final-Billed A/R

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Indicator

Purpose

Value

Calculation

Point-of-Service Cash Collections

Trending indicator of point-of-servicecollection efforts

Indicates potential exposure to baddebt, accelerates cash collections,and can reduce collection costs

POS Payments

Total Patient Cash Collected


HFMA s MAP Initiative MAP Keys: Point-of-Service Cash Collections ($)

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Indicator

Purpose

Value

Calculation

Cost to Collect

Trending indicator of operationalperformance

Indicates the efficiency andproductivity of RC process

Total RC Cost

Total Cash Collected


HFMA s MAP Initiative MAP Keys: Cost to Collect

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Indicator

Purpose

Value

Calculation

Cash Collections as a Percentage of Adjusted Net Patient-Service Revenue

Trending indicator of propensity toconvert net revenue to cash

Indicates fiscal integrity / financialhealth of the organization

Total Cash Collected

Average Monthly Net Revenue


HFMA s MAP Initiative MAP Keys: Cash Percentage of Net Revenue

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Indicator

Purpose

Value

Calculation

Bad Debt

Trending indicator of the effectivenessof self-pay collection efforts andfinancial counseling

Indicates organization’s ability tocollect self-pay accounts andidentify payor sources for patientsunable to meet financial obligations

Bad Debt Write-Off

Gross Patient Service Revenue


HFMA s MAP Initiative MAP Keys: Bad Debt (%)

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Indicator

Purpose

Value

Calculation

Charity Care

Trending indicator of local ability topay

Charity Care Write-Off

Gross Patient Service Revenue


HFMA s MAP Initiative MAP Keys: Charity Care (%)

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Indicates organization’s ability tocollect self-pay accounts andidentify payor sources for patientsunable to meet financial obligations



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Indicator

Purpose

Value

Calculation

Days in Total Discharged Not FinalBilled

Trending indicator of local ability topay

Indicates RC performance and canidentify performance issuesimpacting cash flow

Gross Dollars in DNFB A/R

Average Daily Gross Revenue


HFMA s MAP Initiative MAP Keys: Days in Total DNFB

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Indicator

Purpose

Value

Calculation

Aged A/R as a % of Billed A/R, byPayor Group

Trending indicator of receivablescollectability, by payor group

Indicates RC’s ability to liquidate A/R,by specific payor group

Billed Payor Group by Aging(>30,>60,>90,>120 days)

Total Billed A/R by payor group


HFMA s MAP Initiative MAP Keys: Aged A/R Percentage of Billed A/R by Payor

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Indicator

Purpose

Value

Calculation

Days in Final Billed Not Submitted toPayor (FBNS)

Trending indicator of claims delayedby payor / regulatory edits in theclaims processing system

Track the impact of internal / externalrequirements for clean claimproduction, which impact cash flow

Gross Dollars in FBNS

Average Daily Gross Revenue


HFMA s MAP Initiative MAP Keys: Days in FBNS

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Indicator

Purpose

Value

Calculation

Days in Total Discharged NotSubmitted to Payer (DNSP)

Trending indicator of total claims-generation / submission effectiveness

Indicates revenue cycle performanceand can identify performance issuesimpacting cash flow

Gross $ in DNFB + Gross $ in FBNS Average Daily Gross Revenue


HFMA s MAP Initiative MAP Keys: Days in DNSP (DNFB + FBNS)

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Indicator

Purpose

Value

Calculation

Late Charges as % of Total Charges

Measure of revenue-integrityeffectiveness

Identify opportunities to improverevenue integrity, reduce avoidablecosts, enhance compliance, andaccelerate cash flow

Charges with posting dates greaterthan 3 days from final service date

Total gross charges


HFMA s MAP Initiative MAP Keys: Late Charge Percentage

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Indicator

Purpose

Value

Calculation

Initial Denial Rate – Zero-Pay Claims

Trending indicator of percentage ofclaims not paid

Indicates provider’s ability to complywith payor requirements and payor’sability to accurately pay claims

Number of zero-pay claims deniedNumber of total claims remitted


MAP Keys: Initial Zero-Pay Denial Rate (#)

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Indicator

Purpose

Value

Calculation

Initial Denial Rate – Partial-Pay Claims

Trending indicator of percentage ofclaims partially paid (underpaid)

Indicates provider’s ability to complywith payor requirements and payor’sability to accurately pay claims

Number of partial-pay claims deniedNumber of total claims remitted


MAP Keys: Initial Partial-Pay Denial Rate (#)

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Indicator

Purpose

Value

Calculation

Denials Overturned on Appeal

Trending indicator of provider’s successin managing the appeal process

Indicates opportunities for payor andprovider process improvement andcash-flow improvements

Number of appealed claims paidTotal number of claims appealed and

finalized or closed


MAP Keys: Appeals Success Rate (#)

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Indicator

Purpose

Value

Calculation

Net Days Revenue in Credit Balances

Trending indicator to accurately report A/R values, ensure regulatorycompliance, and monitor overall

A/R management effectiveness

Indicates whether credit balances aremanaged to appropriate levels and arecompliant w/ regulatory requirements

Dollars in Credit Balances

Average Daily Net Patient-ServiceRevenue

Purpose | Value | CalculationMAP Keys: Net Days in A/R Credits

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Indicator

Purpose

Value

Calculation

Pre-Registration Rate

Trending indicator of timeliness,accuracy, and efficiency of patient

access processesIndicates revenue cycle efficiency and

effectiveness

Number of patient encounters

pre-registered

Number of scheduled patient

encounters


MAP Keys: Pre-Registration Rate

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Indicator

Purpose

Value

Calculation

Insurance Verification Rate

Indicates revenue cycle processefficiency and effectiveness

Total number of verified encounters

Total number of registered encounters


MAP Keys: Insurance Verification Rate

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access processes



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Indicator

Purpose

Value

Calculation

Service-Authorization Rate

Indicates revenue cycle processefficiency and effectiveness

Number of encounters authorizedNumber of encounters requiring

authorization


MAP Keys: Service-Authorization Rate

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access processes


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Let’s get down to details…



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Scheduling

Pre-Registration / Pre-Authorization Insurance Verification

Patient Access / Registration


Health Information Management

Charge Entry / Revenue Protection

y



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Billing / Claim Submission

3rd-Party and Guarantor Follow-Up Cashiering / Refunds / Adj Posting

Denials

Customer Service

Collection / Outsourcing Vendors

Physician Practice Management

Managed Care Contracting



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Scheduling

KPI Description Standard1. Overall scheduling rate of potentially-eligible patients: 100%

Scheduling rate for elective and urgent inpatients 100%

Scheduling rate for ambulatory surgery patients 100%

Scheduling rate for hi-$ outpatient diagnostic patients 100%

2. Scheduled patients’ pre-registration rate 98%



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KPI Description Process

1. Use on-line scheduling software house-wide? Yes

2. Have central scheduling unit? Yes

3. Central scheduling answers to Chief Revenue Officer? Yes

4. Surgery uses same scheduling software as other depts? Yes

5. Scheduling system integrated with registration system? Yes

6. Use on-line OP medical necessity system prior to service? Yes

7. Pre-certification requirements shared with MDs’ offices? Yes

Scheduling



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8. MDs and patients able to make on-line appt requests? Yes

9. Non-emergency services scheduled 12+ hours in advance? Yes

10. Process and IT integrated between scheduling and pre-reg? Yes

11. Services postponed if not pre-authorized in advance? Yes

12. Financial counseling part of scheduling process? Yes

Patient balances and payment obligations discussed? Yes

Hospital policy for point-of-service payment explained? Yes

Reminder to bring required payment & insurance cards given? Yes

Scheduling



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Pre-Registration / Pre-Authorization

KPI Description Standard1. Overall pre-registration rate of scheduled patients ≥ 98%

2. Overall insurance verification rate of pre-registered patients ≥ 98%

3. Deposit request rate for co-pays and deductibles ≥ 98%

4. Deposit request rate for elective admissions / procedures ≥ 100%

5. Deposit request rate for prior unpaid balances ≥ 98%

6. Data quality compared to pre-established dept standards ≥ 99%



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Pre-Registration / Pre-Authorization

KPI Description Process1. Have dedicated pre-registration / pre-authorization unit? Yes

2. Process and IT integrated between scheduling and pre-reg? Yes

3. Services postponed if not pre-authorized in advance? Yes

4. Financial counseling part of pre-reg / pre-auth process? Yes

Patient balances and payment obligations discussed? Yes





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Insurance Verification

KPI Description Standard

1. Overall insurance verification rate of scheduled patients ≥ 98%

2. Overall ins verification rate of pre-registered patients ≥ 98%

3. Ins verf rate of unscheduled IPs w/in one day ≥ 98%

4. Ins verf rate of unscheduled hi-$ OPs w/in one day ≥ 98%




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KPI Description Process1. Have dedicated insurance verification unit? Yes

2. Process and IT integrated between ins verf / patient access? Yes

3. Use on-line insurance verification system? Yes

4. Financial counseling part of insurance verification process? Yes

Alternate arrangements for non-covered patients explored? Yes



Insurance Verification



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1. Average registration interview duration ≤ 10 min

2. Average patient wait time ≤ 10 min

3. Average IP registrations per registrar / per shift 35

4. Average OP registrations per registrar / per shift 40

5. Average ER registrations per registrar / per shift 40


7. ABNs / MSPQs obtained when required 100%

8. MPI duplicates created daily as a % of total registrations ≤ 1%



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1. Patient Access reports to Chief Revenue Officer? Yes

2. All registrars report to Patient Access or within rev cycle? Yes

3. Use on-line document imaging system? Yes

4. Financial counseling part of patient access process? Yes

Patient balances and other payment obligations collected? Yes

Policy for payment alternatives explained (credit cards, etc.)? Yes

Copies of required payment & insurance cards obtained? Yes



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5. Registrars’ incentive compensation tied to quality indicators? Yes

6. Registration system integrated / interfaced to PFS system? Yes

7. Use on-line / web-enabled patient self-registration system? Yes

8. Use on-line OP medical necessity system prior to service? Yes

9. Use on-line registration data quality tracking system? Yes

10. Have on-line interface to owned MDs’ registration system? Yes




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1. Collection of elective services deposits prior to service 100%

2. Collection of IP patient-pay balances prior to discharge ≥ 65%

3. Collection of OP patient-pay balances prior to service ≥ 75%

4. Collection of ER patient-pay balances prior to departure ≥ 50%

5. Screening of uninsured IPs and hi-bal OPs for fin assist ≥ 98%

6. Pmt arrangements for non-charity eligible IPs / hi-bal OPs ≥ 98%

7. Prompt-payment discount percentage(s) 05 – 20%



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1. Financial counseling reports to Chief Revenue Officer? Yes

2. Uninsured IPs and high-balance OPs screened for fin assist? Yes

Medicaid eligibility? Yes

State, local, and hospital charity programs? Yes

Grants / studies, etc.? Yes

3. Financial counselors interview patients in their rooms? Yes

4. Prompt payment discounts offered? Yes



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5. Fin counselors’ incentive compensation tied to collections? Yes

6. Discuss pmt alternatives w/ non-charity eligible patients? Yes

Credit cards? Yes

Bank-loan financing? Yes

Interest-bearing hospital-funded payment arrangements? Yes

7. All IPs cleared thru financial counselors before discharge? Yes

8. Proof of income / assets obtained from charity applicants? Yes



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KPI Description Standard1. IP charts coded per coder / per day 20 - 24

2. OBSV charts coded per coder / per day 32 - 36

3. AMB SURG charts coded per coder / per day 32 – 36

4. OP charts coded per coder / per day 130 – 210

5. ER charts coded per coder / per day 130 - 210

6. Chart delinquency greater than 30 days ≤ 5%

7. Total chart delinquency ≤ 10%

KPIs by Functional AreaH l h I f i M


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8. HIM “DRG development” hold greater than late charge hold ≤ 2 A/R days

9. Copies of medical records pursuant to payors’ requests ≤ 2 work days

10. Transcription rate per line 08 – 12¢

11. Transcription backlog ≤ 1 work day

12. Chart retrieval pursuant to MDs’ requests ≤ 90 minutes

13. MPI duplicates as a % of total MPI entries ≤ .5%

14. PEPPER1 potential “over-codes” beyond 75th percentile ≤ 2%

15. PEPPER potential “under-codes” below 10th percentile ≤ 2%

1 Program for Evaluation Payment Patterns Electronic Report

KPIs by Functional AreaH lth I f ti M t


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1. Health Info Management reports to Chief Revenue Officer? Yes

2. Use on-line DRG and APC groupers? Yes

3. Use on-line, bar-code enabled chart location system? Yes

4. Use on-line, scanning-enabled HIM records imaging system? Yes

5. Use on-line and/or voice-recognition transcription system? Yes

6. Use on-line clinical abstracting system ? Yes

7. MDs able to view and/or e-sign records outside the hospital? Yes

KPIs by Functional AreaHealth Information Management


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8. Storage / retrieval / release of records HIPAA-compliant? Yes

9. Use on-line, up-to-date coding compliance system? Yes

10. All coding done by employees reporting to HIM Director? Yes

11. All coding done by certified coders who are retrained often? Yes

12. All coding done in descending balance order, not FIFO ? Yes

13. All coding done in “best payor” order (FFS, MCR, HMO)? Yes

14. All coding done when info is sufficient, not 100% complete? Yes



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15. Receive and discuss denials info provided by PFS or others? Yes

16. Provide and discuss denials / delinquency info with MDs? Yes

17. Have effective tracking system to locate missing records? Yes

18. Have appropriate staffing to prevent process backlogs? Yes

19. Consistently monitor / control D-N-F-B A/R due to HIM? Yes

20. Perform internal quality-control audits at least quarterly? Yes

21. Have external quality-control audits done at least annually? Yes



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22. Review PEPPER to compare MCR pmts w/ state & nat’l avgs? Yes

23. Use PEPPER to identify problem-prone DRGs? Yes

24. Use PEPPER / OIG Work Plans to focus internal reviews? Yes

25. Track / trend all outside record-audit requests? Yes

26. Self-review all charts selected for audit by RACs / others? Yes

27. Submit all self-reviews w/ “Things Done Right” cover letters? Yes


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KPIs by Functional AreaCharge Entry / Revenue Integrity


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Charge Entry / Revenue Integrity


8. CDM item has invalid / incorrect modifier 0

9. CDM item has missing modifier 0

10. CDM item price less than HOPPS APC rate 0

11. CDM item price is $0 0

12. CDM item description is “Miscellaneous” 0

13. CDM item description / price is editable on-line 0



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1. CDM Coordinator reports to Chief Revenue Officer? Yes

2. Have formal CDM change management process? Yes

3. Have formal annual CDM review process with clinical depts? Yes

4. Modifiers “static coded” in CDM; chosen via order-entry sys? Yes

5. All charge items ordered via on-line order-entry system? Yes

6. Late / lost charge perf stds in dept mgrs’ job descriptions? Yes

7. Annual HCPCS / CPT-4 changes in place by Jan each year? Yes



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8. Surgery HCPCS / CPT-4 appear in UB-04 form locator 44? Yes

9. Surgery lab / X-ray charges properly unbundled? Yes

10. CDM pricing methodology standardized / defensible? Yes

11. Depts understand difference between “billable” / “payable?” Yes

12. CDM items have Patient Friendly Billing ® descriptions? Yes

13. Have formal annual charge sheet / ticket review process? Yes

14. Receive / review CPT-4 manual / Addendum B annually? Yes



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15. Nursing procedures (CPR, infusion, etc.) built into CDM? Yes

16. HIM assigns interventional / surgical procedure codes? Yes

17. ER Nursing levels match Medicare descriptions? Yes

18. MDs’ OP orders received with requisite CPT-4 code(s)? Yes

19. Order entry items map accurately to service codes? Yes

20. Charge tickets, etc. map accurately to service codes? Yes

21. Appropriate charge in CDM for all services delivered? Yes



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22. Charge data flow reliably from points of service to claims? Yes

23. Modifiers are conveyed correctly / reliably to claims? Yes

24. CCI edit conflicts controlled by correct reg / charge entry? Yes

25. Units of service accurate / flow reliably to claims? Yes

26. Clinical depts’ “charge awareness” monitored / enhanced? Yes

KPIs by Functional AreaBilling / Claim Submission


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1. HIPAA-compliant electronic claim submission rate 100%

2. Final-billed / claim not submitted backlog ≤ 1 A/R day

3. Medicare supplement ins billing following adjudication ≤ 2 bus days

4. Non-Medicare COB-2 ins billing following COB-1 payment ≤ 2 bus days

5. Medicare RTP (Return To Provider) denials rate ≤ 3%

6. Outsourced guar stmt cost to produce / mail (w/out stamp) 20 - 25¢



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1. Primary / secondary billing completed by dedicated team? Yes

2. Staffing sufficient to minimize / prevent billing backlogs? Yes

3. Quantity / quality perf stds part of billers’ job descriptions? Yes

4. Perform regular quality control reviews of billers’ work? Yes

5. All billers finish CMS’s Medicare billing training? Yes

6. All billers receive annual Medicare compliance training? Yes

7. Billers cross-trained on more than one payor type? Yes



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KPI Description Process8. Use on-line electronic billing system? Yes

Easy to add new billing edits? Yes

Automatic daily downloads from PFS system? Yes

Provides final-bill download reconciliation reports? Yes

Provides biller-specific worklists? Yes

Major-payor edits supplied / supported by vendor? Yes

Claim-submit notice automatically uploaded to PFS system? Yes

Claim corrections automatically uploaded to PFS system? Yes



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8. Use on-line electronic billing system (con’t)? Yes

All claims (paper + electronic) editable? Yes

Standard errors automatically corrected? Yes

Provides biller-specific productivity and error reporting? Yes

Provides clinical department-specific error reporting? Yes

Automates Medicare-supplement / COB-2 claim submission? Yes

Interfaces with on-line Medicare-compliance system? Yes



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9. Use Patient Friendly Billing ® concepts for guarantor billing? Yes

10. Use proration to bill ins and guarantor simultaneously? Yes

11. Guarantor stmts include credit card option? Yes

12. Guarantor stmts clearly communicate payment policies? Yes

13. Guarantor stmts provide customer service phone number? Yes

14. Guarantor stmts provide customer service web address? Yes

15. Guarantor billing cycle designed to optimize collections? Yes

KPIs by Functional Area3rd -Party and Guarantor Follow-Up


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3 Party and Guarantor Follow Up


1. Ins A/R aged more than 90 days from service / discharge ≤ 15 - 20%

2. Ins A/R aged more than 180 days from service / discharge ≤ 5%

3. Ins A/R aged more than 365 days from service / discharge ≤ 2%

4. Bad debt write-offs as a % of gross revenue ≤ 3%

5. Charity write-offs as a % of gross revenue ≤ 3%

6. Cost-to-collect ([PA + PFS + agency expenses] cash) ≤ 3%

7. A/R cash as a % of net revenue ≥ 100%



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8. In-House A/R days ≤ ALOS

9. D-N-F-B A/R days ≤ 4 – 6 A/R days

10. Net A/R days ≤ 50 A/R days

11. A/R cash as a % of cash goal ≥ 100%

12. Total point-of-service cash as a % of cash goal ≥ 2 - 3%



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1. High-balance follow-up completed by dedicated team? Yes

2. Staffing sufficient to minimize / prevent aged A/R build-up? Yes

3. Quantity / quality perf stds part of collectors’ job descriptions? Yes

4. Perform regular quality control reviews of collectors’ work? Yes

5. All collectors finish CMS’s Medicare billing module? Yes

6. All collectors receive annual Medicare compliance training? Yes

7. Collectors cross-trained on more than one payor type? Yes



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KPI Description Process8. Use on-line “receivables work station” system? Yes

Easy to add new collector assignments? Yes

Automatic daily downloads from PFS system? Yes

Provides download reconciliation reports? Yes

Full interface for collection notes, etc. to PFS system? Yes

Provides collector-specific worklists? Yes

Worklists presented in descending-balance order? Yes

Next activity date automatically uploaded to PFS system? Yes



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9. Use on-line, web-enabled 3rd-party payor inquiry system(s)? Yes

10. Guarantor follow-up outsourced or on predictive dialer? Yes

11. Collectors receive 3rd-party / guarantor follow-up training? Yes

12. Collectors use 3rd-party / guarantor follow-up scripts? Yes

13. Collectors have no competing duties (customer svc, etc)? Yes

14. Collectors receive performance-based incentive comp? Yes

KPIs by Functional AreaCashiering / Refunds / Adjustment Posting


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Cas e g / e u ds / djus e os g

KPI Description Standard1. HIPAA-compliant electronic payment posting % 100%

2. Transaction posting backlog (during the month) ≤ 1 bus day

3. Transaction posting backlog (end of the month) 0 bus days

4. Credit-balance A/R days (gross) ≤ 2 A/R days

5. Medicare credit-balance report submission timeliness ≤ due date



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g j g


1. Cashiering completed by dedicated team w/ no other duties? Yes

2. Refunds completed by dedicated team w/ no other duties? Yes

3. Quantity / quality perf stds part of cashiers’ job descriptions? Yes

4. Perform regular quality control reviews of cashiers’ work? Yes

5. All cashiers receive annual Medicare compliance training? Yes

6. Cashiers cross-trained on more than one payor type? Yes



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g j g


8. Use lockbox for non-electronic / non-EDI payments? Yes

9. Lockbox remits payment data electronically / EDI / OCR / 835? Yes

10. Denial transaction codes entered to facilitate follow-up? Yes

11. Use on-line system to compare expected vs. actual pmts? Yes

12. Post contractual adjustments at time of final billing? Yes

KPIs by Functional AreaDenials / Underpayments


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p y

KPI Description Standard1. Overall initial denials rate (% of gross revenue) ≤ 4%

2. Clinical initial denials rate (% of gross revenue) ≤ 5%

3. Technical initial denials rate (% of gross revenue) ≤ 3%

4. Underpayments additional collection rate ≥ 75%

5. Appealed denials overturned rate 40 – 60%



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p y


6. Electronic eligibility rate ≥ 75%

7. Physician pre-certification double-check rate 100%

8. Case managers’ time spent securing authorizations rate ≤ 20%

9. Total denial reason codes ≤ 25



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p y


1. Denials tracked by payor, reason, financial consequence? Yes

2. Denials distinguished between technical and clinical? Yes

3. Denials tracked by physician, DRG, and department? Yes

4. Contractual allowances increasing slower than gross rev? Yes

5. Dedicated denials unit w/ payor-specific appeals experience? Yes

6. Respond to clinical documentation requests w/ in 14 days? Yes

7. Use on-line system to compare expected vs. actual pmts? Yes



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p y


8. Use on-line payment tracking software? Yes

9. Use on-line contract management software? Yes

10. Maintain denials database; self-developed or purchased? Yes

11. Use on-line OP med necessity system prior to billing or svc? Yes

12. All denial reason codes actionable? Yes

13. OBSV and IP authorizations tracked separately? Yes

14. Pre-cert, auth, and re-cert functions in a single department? Yes



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y


15. Pre-certification requirements shared with MDs’ offices? Yes

16. Provide MDs with regular feedback on clinical denials rates? Yes

17. Hold regular payor meetings to discuss denials issues? Yes

18. Contract terms regularly distributed to rev cycle employees? Yes

19. Rev cycle employees learn of contract changes in advance? Yes

20. Structured feedback between rev cycle and mgd care depts? Yes

21. Non-emergency services scheduled 12+ hours in advance? Yes

KPIs by Functional AreaCustomer Service


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1. Correspondence backlog ≤ 1 bus day

2. Walk-in patients’ wait time ≤ 5 min

3. ACD system average hold time ≤ 2 min

4. ACD system abandoned call % (calls on hold ≥ 30 seconds) ≤ 2%

5. ACD system % of calls answered in ≤ 20 seconds ≥ 75%

6. ACD system % of calls resolved in ≤ 5 minutes ≥ 85%

7. ACD system % of calls not resolved in ≥ 10 minutes ≤ 5%

8. Calls resolved in unit, w/out complaint / referral to Dir PFS ≥ 95%



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1. Cust service handled by dedicated team w/ no other duties? Yes

2. CS unit responsible for walk-ins, phone calls, mail, & e-mail? Yes

3. Quantity / quality perf stds part of CS reps’ job descriptions? Yes

4. Perform regular quality control reviews of CS reps’ work? Yes

5. All CS reps receive annual Medicare compliance training? Yes

6. CS reps cross-trained on more than one responsibility? Yes



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7. CS reps cross-trained on most / all PFS system functions? Yes

8. Use voice-mail sys so patients can request basic info / IBs? Yes

9. Use ACD (Automated Call Distribution) system? Yes

10. ACD system automatically maintains unit / rep statistics? Yes

KPIs by Functional AreaCollection / Outsourcing Vendors


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KPI Description Standard1. Bad debt netback ([collections – fees] placements) % 7 – 11%

2. Bad debt fee % 15 – 18%

3. 3

rd

-party EBO (Extended Bus Ofc) fee % (IP + OP + ER blend) 6 - 10%

4. Self-pay EBO fee % (IP + OP + ER blend) 10 – 12%

5. Legal collections fee % 20 – 30%

6. Medicaid eligibility assistance fee % 12 – 18%



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1. Use two or more bad debt agencies? Yes

2. Use different agencies for bad debt and EBO? Yes

3. Write off long-term payment accts / use agency to monitor? Yes

4. Apply Medicare bad debt “120 days” rule to all fin classes? Yes

5. Agencies / outsource vendors accept referrals electronically? Yes

6. EBO vendor able to “mirror” PFS system to get notes, etc.? Yes

7. Medicaid elig vendor have good relations w/ State agencies? Yes



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8. Agencies remit gross payments / submit invoices for fees? Yes

9. Agencies willing to put own support FTEs on-site? Yes

10. Agencies willing to assign dedicated FTEs to your accounts? Yes

KPIs by Functional AreaPhysician Practice Management


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KPI Description Standard1. Visits w/out charges as % of total visits 0%

2. Co-pay collections as % of total co-pay office visits ≥ 95%

3. EDI claims as % of total claims ≥ 90%

4. Charge-entry lag period ≤ 1 bus day

5. Claims passing claim edits as % of total claims ≥ 98%

6. Appointment no-show rate ≤ 2 - 3%



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KPI Description Standard7. Appointment bumped rate ≤ 2 - 3%

8. Net A/R days (non-specialty practices) ≤ 40 days

9. Collections as % of net revenue ≥ 100%

10. Collections as % of gross revenue (non-specialty practices) ≥ 60%

11. 3rd-Party A/R aging > 90 days from service date ≤ 10%

12. Denials as % of net revenue (including “incidental to” svcs) ≤ 2%



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KPI Description Standard13. Claims w/ no activity > 90 days from last activity date 0%

14. Credit balances ≤ 2 A/R days

15. Average patient wait time after office arrival ≤ 15 minutes



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1. Send voice and mail reminders for regular annual visits? Yes

2. Send voice and mail reminders for other scheduled visits? Yes

3. Use “open scheduling” Yes

to increase walk-in capacity? Yes

to minimize appointment bumping? Yes

to increase patient satisfaction? Yes

to reduce nursing callbacks? Yes



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4. Calculate net revenue and net receivables? Yes

5. Use dedicated billing / follow-up FTEs w/ no other duties? Yes

6. Use collection agencies? Yes


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Let’s pause and define terms...Contracting Cycle

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KPIs by Functional AreaContracting Cycle Definition


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1. Providepatients

4. Payclaims

2. Treatpatients

3. Submitclaims



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Reduce Payor Discretion

Achieve Target Margins



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Analyze

ServiceLines

Understand Payors &Their Reputations

AnalyzeSteerage vs.

Discounts

Submit &Follow-up

Claims

Work Denials &Payment Variances

Collect Accounts &Post Payments

AnalyzeFinancialNeeds

Define Payor’s &Provider’s Duties

UnderstandCompetitors

& Market

Negotiate ContractLanguage & Rates

AnalyzeContractPerformance



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Strategy development

Strategy implementation

Contract negotiations

Contract evaluation

Forecasting and analysis Contract implementation and operations

Performance monitoring

Strategic issues and planning

SOURCE: Stevenson, “Managed Care Cycle Provides Contract Oversight,” hfm

KPIs by Functional AreaManaged Care Contracting


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KPI Description Standard1. Rate increases compared to CPI medical-care component ≥ CPI MCC

2. Outlier $ fraction of total contract revenue 5%

3. Contract profitability compared to IRR “hurdle rate” ≥ IRR HR

4. Eligibility / authorization / certification availability 24 / 7 / 3655. Retro review / timely filing periods (keep in balance) 90 – 120 days

6. Termination notification period (without cause) 90 days

7. Renegotiation planning begins prior to renewal date 6 months

8. Optimal contract term 2 – 3 years



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KPI Description Process1. Contract contains automatic renewal clause? Yes

2. Contract contains inflation index? Yes

3. All hospital services included / specific exclusions defined? Yes

4. Termination notification period = 90 days? Yes

5. Duties for on-going patient care / pmt at termination defined? Yes

6. ABN or equivalent acceptable for non-covered services? Yes

7. Provider authorized to bill guarantor for non-covered svcs? Yes

8. Hospital-based MDs use hospital-obtained authorizations? Yes

SOURCE: “Managed Care Forum Contracting Checklist,” HFMA Wants You to Know



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KPI Description Process9. Provider authorized to collect deposits for non-covered svcs? Yes

10. Contract discloses all sub-contracting relationships? Yes

11. Contract contains an independent contractor clause? Yes

12. Contract excludes “most favored nation” provisions? Yes13. Contract start date clearly defined (to prevent A/R build up)? Yes

14. Contract stipulates all parties pay own legal fees? Yes

15. Definition / criteria for all key terms clearly stipulated? Yes

Medical necessity? Yes

Emergency condition / emergency admission? Yes




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KPI Description Process15. Definition / criteria for all key terms clearly stipulated (con’t)? Yes

Trauma / trauma services / trauma team? Yes

Covered services? Yes

Material breach? Yes

Prompt payment? Yes

Stop-loss / outlier? Yes

Carve-out? Yes

Medicare rate? (should include pass-throughs) Yes




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Sentinel event(s)? Yes

Medical-loss ratio? Yes

Silent PPO? Yes

Clean claim? Yes

Timely notification / timely filing? Yes

Authorization / certification? Yes




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Service level(s)? Yes

Denial / rejection / null event? Yes

Negotiation / mediation / arbitration? Yes

Plan agreement? Yes

Inpatient / outpatient / emergency patient / obsv patient? Yes

Substantial impact? Yes

Member / insured / dependent? Yes




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KPI Description Process16. Advance notice time for contract changes clearly stipulated? Yes

Payment / reimbursement rates? Yes

Covered services / procedures? Yes

Plan documents / requirements? Yes

Major employer groups? Yes

17. Contract includes warranty of HIPAA compliance? Yes

18. Contract forbids reassignment without mutual consent? Yes

19. Payor’s reporting requirement duties clearly stipulated? Yes




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KPI Description Process20. Contract clearly material to provider’s revenue stream? Yes

21. Eligibility verification process clearly stipulated? Yes

22. Medical necessity verification process clearly stipulated? Yes

23. Prior authorization process clearly stipulated? Yes

24. Payor provides all customers’ contract / policy manuals? Yes

25. Payor provides copies of all administrative / policy manuals? Yes

26. Appeal / independent review processes clearly stipulated? Yes

27. Payor precluded from changing reimbursement unilaterally ? Yes

SOURCE: “15 Questions to Ask Before Signing a Managed Care Contract,” PrivateSector Advocacy



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KPI Description Process28. Payor’s prompt payment duty clearly stipulated? Yes

29. Payor agrees to pay interest on late payments? Yes

30. Contract complies with statutory processing / pmt duties? Yes

31. Payor precluded from “takebacks” / “offsets”? Yes

32. “Retro review” period balanced to “timely filing” period? Yes

33. Contract precludes participating in / enabling “Silent PPOs”? Yes

34. Termination provisions / timing clearly stipulated? Yes

35. Contract terms supersede provisions in Provider Manual? Yes

SOURCE: “15 Questions to Ask Before Signing a Managed Care Contract,” PrivateSector Advocacy



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KPI Description Process36. Perform annual “internal” analysis of all contracts? Yes

Contractual discounts balanced to gross volumes / net rev? Yes

Use analysis to identify renegotiation / termination targets? Yes

Compare all contracts to Medicare fee schedule? Yes

Calculate relative profitability using payor-specific costs? Yes

All contracts cover their direct costs, at minimum? Yes

Use relative profitability for leverage during renegotiation? Yes

Recognize internal review cannot I.D. below-mkt contracts? Yes

Recognize internal review silent on case mix/stop-loss/etc.? Yes

SOURCE: Wilson, David et al, “3 Steps to Profitable Managed Care Contracts,” hfm



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KPI Description Process37. Perform annual “external” analysis of all contracts? Yes

Compare (legally) your rates to those of similar providers? Yes

Use outside firms / databases to obtain comparative info? Yes

Challenge data’s age / geographic relevance before using? Yes

Compare specific service lines, as well as overall rates? Yes

Target biggest upside opportunities during renegotiation? Yes

Compare pmt structures (charge % / DRGs) + overall rates? Yes

Understand impact of I/P stop-loss / O/P max-pay clauses? Yes

Try to end all “cost-plus” pmts in favor of % of charges? Yes




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KPI Description Process37. Perform annual “external” analysis of all contracts (con’t)? Yes

Review contract language, especially key terms / clauses? Yes

Claim submission and payment Yes

Protection against catastrophic cases Yes

Procedure-based carve-out payments Yes

Stop-loss payment structures Yes

Pmts for implants / prosthetics / orthotics / high-$ drugs Yes

Cut-off date for timely filing / retro review / refunds / etc. Yes

Utilization review process Yes New services / technologies Yes




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KPI Description Process37. Perform annual “external” analysis of all contracts (con’t)? Yes

Compare payment levels to premium increases? Yes

Ensure rate trends mirror premium increase trends? Yes

Compare payors’ relative profitability trends? Yes

Compare rate trends to medical-care component of CPI? Yes




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KPI Description Process38. Conduct annual “pmt performance” analysis of all contracts? Yes

Contracts comply with statutory processing / pmt regs? Yes

Report habitual violators to Insurance Commissioner? Yes

Compare payors’ denial / pmt discrepancy trends, by group? Yes

Insurance plan? Yes

Patient type? Yes

Service line? Yes

Reason code? Yes

Physician? Yes




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KPI Description Process39. Contract defines documentation req’d to prove timely filing? Yes

40. Contract reviewed by attorney before renewal? Yes

41. “Soft” contract provisions (“quality” / “affordable”) avoided? Yes

42. “Reasonable efforts” term used to define providers’ duties? Yes

43. Both parties agree not to disclose negotiated rates? Yes

44. Supplemental documents included by reference / attached? Yes

45. Amendments required in writing with mutual signatures? Yes

46. Participating corporations / entities clearly stipulated? Yes

47. Assignment clauses clearly stipulated / require signatures? Yes

SOURCE: Miller, Thomas, “Conducting a Managed Care Contract Review,” HealthcareFinancial Management



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KPI Description Process48. “Start up” payors post security deposit / letter of credit / etc? Yes

49. Contract parties independent and able to compete? Yes

50. Provider listed as “participating” in directories / websites? Yes

51. Complete list of covered services attached to contract? Yes

52. Provider can reduce malpractice ins to state law minimums? Yes

53. Ambiguous service descriptions avoided? Yes

Avoid “services including but not limited to” Yes

Avoid “services customarily provided” Yes

Avoid “services covered by the plan” Yes




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KPI Description Process54. Services not directly provided defined / contracted in adv? Yes

Out-of-area services Yes

Hospital-based physician services Yes

55. Capitation rates / benefits design (if any) clearly stipulated? Yes

56. Flat-rate contracts w/ payors known for excessive bundling? Yes

57. Licensing / JCAHO standards adequate for credentialing? Yes

58. Provider not required to report “in accordance with HEDIS?” Yes

59. Contract / payment terms administratively feasible? Yes

60. Current HIS adequate to handle contract terms / A/R needs? Yes




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KPI Description Process61. Mutual information requirements clearly stipulated? Yes

Specific information / reports described? Yes

“Information including but not limited to” avoided? Yes

Provider’s confidential / proprietary information protected? Yes

Provider’s duty to provide info to payor strictly limited? Yes

Payor obligated to reimburse costs of providing records? Yes

SOURCE: Miller, Thomas, “Conducting a Managed Care Contract Review,” Healthcare

Financial Management



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KPI Description Process62. Mutual duties regarding care reviews clearly stipulated? Yes

63. Provider’s duty to notify payor re: adverse events limited? Yes

No duty re: patient complaints? Yes

No duty re: risk management incidents? Yes

No duty re: physician malpractice suits? Yes

No duty re: physician status changes? Yes

No duty re: medical staff disciplinary actions? Yes

Notify only when sued by members at time of event? Yes

Notify only on intent to report adverse event to regulators? Yes


KPIs by Functional AreaP4P: Clinical Decision Support / Finance


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KPI Description Standard1. P4P Demonstration Project percentile ranking ≥ 80%

2. P4P Demonstration Project bonus achievement ≥ 1%

3. Length of stay, by DRG ≤ DRG avg

4. Readmission rate, by DRG ≤ DRG avg

5. Adherence to quality indicators, by condition ≥ 80%

6. Adherence to quality indicators, by mode ≥ 80%

7. Overall P4P program ROI ≥ 0%

KPIs by Functional AreaP4P: Clinical Decision Support / Finance


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KPI Description Process1. Use advanced clinical systems to support patient care? Yes

2. Use electronic medical record system to support patient care? Yes

3. Use advanced decision support / performance mgt system? Yes

4. Use executive information (scorecard) system? Yes

5. Use “data warehouse” to support DSS / EIS capabilities? Yes

6. Participate in CMS Demonstration Project, if eligible? Yes

7. Have clinical improvement teams in data-enabled depts? Yes

8. Target greatest cost / quality improvement areas first? Yes9 Use “root ca se anal sis” to foc s impro ement efforts? Yes

Accenture - Key Performance Indicators

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