GLOSSARY OF REVENUE CYCLE KEY PERFORMANCE

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COVER STORYDavid C. Hammerperformance is realityhow is your revenue cycle holding up?Do the typical key performance indicators—gross receivables,accounts receivable days, and cash collections—tell youenough about your hospital revenue cycle?AT A GLANCEExpanding your organization’s revenue cycle performance indicatorsbeyond receivables, cash,and A/R days can help you: Keep a record and tell astory Benchmark against yourgoals and industry bestpractices Identify and managetrends, not single-periodresults Illustrate relationshipsbetween key performance indicators“In business, words are words, explanations areexplanations, promises are promises, but onlyperformance is reality.”—Harold S. Geneen,former president and CEO of ITTEnsuring the most effective and efficient revenuecycle is a continuing challenge for most financialmanagers. Naturally, financial leaders focus ondeveloping plans to both improve performance andreduce costs in an extremely complex healthcareenvironment. Each month this complexity is oftenboiled down to only three revenue cycle measurements: gross receivables, accounts receivable days,and cash collections. But are three measurementsreally enough to tell the comprehensive story of yourrevenue cycle performance?Revenue Cycle Performance Indicators:Powerful Benchmarking ToolsOne of the most effective ways to improve performanceand reduce costs is to expand the definition, measurement, and interpretation of your organization’srevenue cycle beyond receivables, cash, and A/R days.Revenue cycle performance indicators are powerfultools for benchmarking against your own goals andagainst industry practices. They help you obtain a morecomplete picture of revenue cycle performance.An expanded set of key indicators is valuable inhelping you do the following.2JULY 2005healthcare financial managementKeep a record and tell a story. How do you know whereyou’re going if you don’t know where you’ve been? Bymaintaining an archive of key indicators in additionto monthly financial statements, managers canunderstand and communicate revenue cycle resultsover time. Revenue cycle performance indicatorsenable the organization to keep a record, take rawdata and turn it into information, and then trend itover time. Trending over time is important becauseit tends to smooth out the variability of using a relative indicator. Once initial success is achieved,departments and individuals across the organizationbegin to buy into the story.Benchmark against your goals and industry best practices.Internal goals may be different from industry standards. For example, in an organization with 100 A/R days, setting a goal of 60 A/R days might demoralize the staff. Setting a “high-stretch goal” of 80 A/Rdays, however, could be a good motivator. Once thatinitial goal is reached, a new high-stretch goal can beestablished.Identify and manage trends, not single-period results.Revenue cycle management is a marathon, not asprint. Therefore, it is important to present goalsand results graphically using trend lines so thatmanagement can focus on long-term results. Whenoverall results are trending in the proper direction,there is less of a tendency to focus obsessively on anysingle period’s result.

COVER STORYGLOSSARY OF REVENUE CYCLE KEY PERFORMANCE INDICATORSKey indicators can be divided into hierarchies, or first-, second-, andthird-level indicators. Most of these indicators should be relative indicators, i.e., they should illustrate a ratio or other arithmetical relationship.First LevelCash collections — Total cash deposited in the bank from all A/Rsources: government, nongovernment, self-pay, and bad-debt recoveryGross and net receivables by component — Total receivables fromall A/R components: in-house, DNFB, and final-billedNet A/R — Total receivables, net of allowances from government,managed care, bad-debt reserve, and other contract payersIn-house and DNFB receivables — Total nondischarged andDNFB A/RThird-party aging percentage greater than 90 days from discharge — Third-party A/R greater than 90 days divided by total thirdparty A/RCash as a fraction of net revenue — Total A/R cash divided by totalnet revenueCost-to-collect percentage — Total patient access plus patient financialservices expense divided by total A/R cash (excludes health informationmanagement expense)Allowance for doubtful accounts — Bad-debt reserveBad debt and charity as a fraction of gross revenue — Bad-debtdollars plus charity dollars divided by gross revenueDenials as a fraction of gross revenue — Technical and clinicaldenials dollars divided by gross revenueCash as a fraction of cash goal — Total A/R cash divided by cashcollection goalPoint-of-service collections as a fraction of goal — Point-of-service cash divided by point-of-service cash goalThird LevelCredit balance receivables — Total dollars in credit-balance statusClean claims throughput percentage — Electronic plus paperclaims passing edits divided by total claimsCollection agency netback percentage — Agency collectionsminus fees divided by agency placementsNet revenue — Total revenue, net of allowances from: government,managed care, bad-debt reserve, and other contract payersCase mix index — Surgical and nonsurgical case mix indexSecond LevelComplaints to administration — Calls and letters logged by administrative secretariesNet A/R days — Net A/R dollars divided by three-month net averagedaily revenueTotal open accounts — Total open accounts from all A/R segments:in-house, DNFB, and final-billedIllustrate relationships between key indicators. Revenuecycle management is an optimizing function in whichmany different objectives must be balanced andresults must be achieved in a limited-resource environment. Consequently, you cannot maximizecollections at the cost of high numbers of complaints,or minimize A/R days at the cost of high bad debt orcontractual write-offs. When interrelationshipsbetween performance indicators are illustrated,revenue cycle management becomes easier.The Three Levels of IndicatorsDifferent audiences are interested in different sets ofindicators. Simply put, higher levels of the organization are interested in more highly aggregated numbers.As you move through the organization closer to the“desk level,” individuals are interested in moredetailed views of revenue cycle outcomes. All revenuecycle performance indicators, however, can and shouldbe shared with all interested parties. Therefore, if thefinance committee is interested in the total number ofopen accounts, include that number in the committee’smonthly revenue cycle report. In turn, revenue cycleleaders should share the finance committee’s numberswith all members of the revenue cycle operation.This uniformity in reporting promotes goal congruence and improves morale. Based on this concept,key indicators can be divided into three groups, orlevels, to be measured and communicated to theorganization. The first group should be presented tothe finance committee—if not the entire board—every month. The second group should be used bythe organization’s C-suite leaders with revenue cycleresponsibility—the CEO, CFO, and chief revenueofficer. Additionally, level 1 and level 2 indicatorsshould be presented at the department head meetingat least quarterly, or every other month, by the chiefrevenue officer. The third group includes activitylevel and other indicators that are more meaningfulto the revenue cycle operations management team.These indicators are also useful for explaining resultvariances that are not otherwise readily understood(for example, variations in case mix index that havean impact on cash collections).The indicators presented in the following sectionsare shown in their most highly aggregated form—thatis, as summary totals for the entire enterprise. Chiefrevenue officers who apply best practice reportingmay often subdivide each performance indicator byhfmJULY 20053

COVER STORYYou cannot maximize collections at thecost of high numbers of complaints, orminimize A/R days at the cost of highbad debt or contractual write-offs.AND NOW,A WORD FROMOUR DICTIONARYp r- for-m n(t)seeThe word performance isfrom the Latin per, “thoroughly,” and furnir, “tocomplete.” The first use ofthe word dates back to the15th century.relevant “sort keys.” These sort keys can includemultiple sites of service (hospitals, clinics, etc.),patient types (inpatient, outpatient, emergency,recurring), payer and/or insurance plans, etc.Having the ability to “drill down” in this fashionallows managers to more quickly identify areaswhere processes may require additional scrutiny.Level 1 IndicatorsIncluded in the first level of indicators are cashcollections, gross and net receivables by component,net A/R, in-house and discharged-not-final-billedreceivables, third-party aging percentage greaterthan 90 days from discharge, cash as a fraction of netrevenue, and cost-to-collect percentage.Cash collections. Cash is king. Executives know howmuch cash is needed each month to meet the organization’s obligations, and they need this number on aconsistent basis as part of the overall financial story.If your organization cannot report cash deposits, anacceptable substitute is to report A/R payments.Gross A/R. Taken directly from the aged trial balance,gross A/R is one of the most accessible figures available to you. It should be the sum of three A/Rsegments—in-house, DNFB, and final-billed receivables. Gross A/R can be a misnomer, however, if yourorganization posts contractual adjustments at time offinal billing. When this occurs, gross A/R may reallybe blended A/R, with in-house and DNFB stated atgross, and final-billed may be a combination of netA/R for contract payers (Medicare, Medicaid, andmanaged care) and gross A/R for self-pay, pendingMedicaid, and so on.Net A/R. Net A/R comes from the finance departmentand is one of the figures the board traditionally seesevery month. It is one of your organization’s mostimportant assets and should be a key focus item. Becareful, however, to look at it in combination withgross A/R. If your A/R aging is deteriorating, yourreserve for uncollectibles may increase and drive downnet A/R, even if gross A/R is flat or even increasing.4JULY 2005healthcare financial managementIn-house and DNFB receivables. These vital components of overall A/R should be reported together andreceive careful attention. Many situations mightcause this A/R segment to require specialized attention—long length-of-stay patients with high-balanceaccounts, coding backlogs due to process problemsor staffing shortages, or compliance issues thatprevent final billing. Without focus, these problemareas might get buried in an overall A/R number.Third-party aging over 90 days. Possibly one of thebest single indicators of overall revenue cycle healthis the percentage of final-billed third-party A/R agedover 90 days from discharge/date of service. Toachieve overall best-practice A/R days results (55 netA/R days or less), you must accelerate third-partycollections. Thus, when this indicator goes down,A/R days will decline commensurately.Cash percentage of net revenue. This is another excellentquick indicator for the health of your overall revenuecycle operation. Especially in turnaround situations,you must collect substantially more than 100 percent ofnet revenue for a substantial period of time to reduceA/R. Generally accepted accounting principles classifybad debt as a period expense, not a deduction fromrevenue. Notwithstanding this treatment, however, thegoal of your revenue cycle should be to collect 100percent or more of net revenue over time. After all, doyou really know how low your A/R days can go?One caveat: You violate the matching principle ofaccounting if you match current month’s cash tocurrent month’s net revenue. Naturally, you can’tcollect all this month’s revenue in the month in whichit is incurred. Over time, the trend line will tell the tale.Cost to collect. This is one of the great “unsung”revenue cycle performance indicators. How manyorganizations measure this indicator? Unfortunately,too few. In many organizations, revenue cycle departments represent a large number of FTEs. And revenuecycle employees are sometimes eligible for incentivecompensation that others don’t receive. Consequently,that can make the revenue cycle a big target. Having anindicator that can demonstrate whether the revenuecycle operation as a whole is doing its job quantifiesthe value of the revenue cycle function itself.Level 2 IndicatorsSix measurements make up the second level of indicator: net A/R days, allowance for doubtful accounts,

COVER STORYTIPS FOR IMPLEMENTING REFINED KEY INDICATORSGet started. Open the discussion on indicators, taking time to define and refine themas needed. Gain consensus and commitment from stakeholders on how indicatorsshould be used to effect change. Consider important questions, including: How do weenter data? How do we get reports? How do we use the information we collect? Whenand why are things out of control? And what do we do about it? Understand, and helpothers understand, the core processes that generate key indicators.Benchmark continuously. Learn how your organization is performing comparedwith regional and national benchmarks. Don’t accept average or top-quartile results.Instead, strive to become a better performer, regularly achieving best-practiceresults. Establish and agree on benchmarks with your board of directors and other keystakeholders, and publish your results to promote continuous quality improvement.Monitor key metrics and processes. Communicate goals and results to allrevenue cycle stakeholders. Educate team members so they understand their rolesand contributions. Illustrate results with charts, graphs, and meaningful reports.Build a performance-oriented culture. Create a culture of accountability andreward that emphasizes the need for adaptation, iteration, and continuous improvement.bad debt and charity as a fraction of gross revenue,denials as a fraction of gross revenue, cash as a fraction of cash goal, and point-of-service collections asa fraction of goal.Net A/R days. This is the “old reliable.” Because it canreceive too much attention at the expense of otherkey indicators, it appears here with the level 2 indicators. Practically speaking, the finance committeeand other constituencies are used to seeing thisnumber. Therefore, it is likely to be included withthe group above. Nevertheless, it should not take theplace of level 1 indicators.Allowance for doubtful accounts. This indicator has aninverse relationship with A/R aging, and it haspossibly the most powerful effect of any key indicatoron profitability. As aging improves, this numberdeclines and profit should increase.Bad debt and charity as a fraction of gross revenue. It isbest to measure this indicator with gross revenue,rather than net, as your divisor. These write-offsalmost always take effect against total charges, eitherin full for pure self-pay accounts or against “firstdollar” deductible and coinsurance accounts.Denials as a fraction of gross revenue. Take care not to be“in denial” about your denials. A denial is a perfectstorm of bad news for your organization. You’ve spentmoney to treat the patient—then you have to write offNet revenue is the keyindicator that can answerthe CFO’s question,“Why are collectionsoff this month?”all the revenue, lose thepotential profit, andcollect zero dollars incash for your trouble.This indicator is highlyaggregated, but anycomprehensive denialssystem will be able toproduce reports sortedin as many ways as youcan imagine.Cash as a fraction of cash goal. When measuringcollections as a fraction of net revenue, resultsusually arrive at mid-month, once the prior month’sbooks have closed. This key indicator allowsmanagers to get results on the first day of the subsequent month, often by setting the cash goal as 100percent of 60-day trailing net revenue. Although thisindicator violates the matching principle ofaccounting, when combined with collections as apercent of net revenue, it offers a good indication ofyour operation’s ability to achieve its primarymission: to put cash in the bank!MUST-DOS FOR REVENUE CYCLE PERFORMANCE INDICATORSKey indicators can help you obtain a complete picture of revenue cycle andbilling/collections performance. Establishing indicators requires that you: Define, measure, and interpret indicators that go beyond gross receivables, cash, andA/R days Develop a comprehensive set of key indicator graphs to communicate revenue cycleperformance with the board, administration, and the revenue cycle management team Relate indicators to one another and understand processes that support achievement of results Understand best-practice goals, upper and lower control limits, and the importanceof managing the trends Perform a mini-assessment of your revenue cycle operations using an improvedfinancial indicators checklist as well as related process steps Use a rigorous set of metrics to help drive continuous improvementhfmJULY 20055

COVER STORYREVENUE CYCLE BEST-PRACTICE STANDARDS AND PROCESSESSCHEDULINGStandardOverall scheduling rate of potentially eligible patientsScheduling rate for elective and urgent inpatientsScheduling rate for ambulatory surgery patientsScheduling rate for high-dollar outpatient diagnostic patientsScheduled patients’ preregistration ratePREREGISTRATION/PREAUTHORIZATIONOverall preregistration rate of scheduled patientsOverall insurance verification rate of preregistered patientsDeposit request rate for copays and deductiblesDeposit request rate for elective admissions/proceduresDeposit request rate for prior unpaid balancesData quality compared with pre-establisheddepartment standardsINSURANCE VERIFICATIONOverall insurance verification rate of scheduled patientsOverall insurance verification rate of preregistered patientsInsurance verification rate of unscheduled inpatientswithin one business dayInsurance verification rate of unscheduled high-dollaroutpatients within one business dayData quality compared with pre-establisheddepartment standardsPATIENT ACCESS/REGISTRATIONAverage registration interview durationAverage patient wait timeAverage inpatient registrations per registrar/per shiftAverage outpatient registrations per registrar/per shiftAverage emergency department registrationsper registrar/per shiftData quality compared with pre-establisheddepartment standardsAdvance beneficiary notices/Medicare secondarypayer questionnaires obtained when requiredMaster patient index duplicates created dailyas a percentage of total registrations100%100%100%100%100%Standard 95% 95% 95% 95% 95% 98%Standard 95% 95% 95% 95% 98%Standard 10 minutes 10 minutes354040 98%100% 1%FINANCIAL COUNSELINGCollection of elective services deposits prior to serviceCollection of inpatient patient-pay balances prior to dischargeCollection of outpatient patient-pay balances prior to serviceCollection of emergency department patient-pay balancesprior to departureScreening of uninsured inpatients and high-balanceoutpatients for financial assistancePayment arrangements for non-charity-eligibleinpatients/high-balance outpatientsPrompt-payment discount percentage(s)HEALTH INFORMATION MANAGEMENTCHARGE ENTRY/REVENUE PROTECTIONhealthcare financial management 50% 95% 95%5-20StandardStandardLate charge hold period2-4 days 2%Late charges as a percentage of total charges 1%Lost charges as a percentage of total chargesChargemaster duplicate items0Chargemaster incorrect/missing HCPCS/CPT-4 codes0Chargemaster incorrect/invalid revenue codes0Chargemaster revenue code lacks necessary HCPCS/CPT-4 code0Chargemaster item has invalid/incorrect modifier00Chargemaster item has missing modifierLevel 3 IndicatorsLevel 3 comprises credit balance receivables, cleanclaims throughput percentage, collection agencynetback percentage, net revenue, case mix index,JULY 2005100% 65% 75%Inpatient charts coded per coder/per day23-26Observation charts coded per coder/per day36-40Ambulatory surgery charts coded per coder/per day36-40Outpatient charts coded per coder/per day150-230Emergency department charts coded per coder/per day190-250 5%Chart delinquency greater than 30 days 10%Total chart delinquencyHealth information management “DRG development”greater than late charge hold 2 A/R daysCopies of medical records pursuant to 2 business dayspayers’ requestsTranscription rate per line8-12 cents 1 business dayTranscription backlog 90 minutesChart retrieval pursuant to physicians’ requests 05%MPI duplicates as a percentage of total MPI entriesPoint-of-service collections as a fraction of goal. Nowmore than ever, healthcare organizations must focuson point-of-service collections to ensure financialhealth. This indicator can be measured in severalways. Some organizations compare point-of-servicecollections with net revenue, pointing toward 2percent to 3 percent. Others compare with potentialcollections, with a goal of collecting 50 percent ormore of total self-pay (deductibles and copaymentson insurance accounts, and total charges on electiveservices and pure self-pay accounts).6Standardcomplaints to administration, and total openaccounts.Credit balance receivables. Credit balance accountsrepresent a liability to the organization. Also, if they aretoo high, they can artificially improve revenue cycleresults. Consequently, some organizations look only atdebit balance A/R when measuring A/R turnover.Nonetheless, you should always have a handle oncredits and strive to keep them as low as possible.Clean claims throughput percentage. In today’sHealthcare Insurance Portability and AccountabilityAct environment, this is one indicator that shouldstart to approach 100 percent. The most stringent wayto measure this quality indicator is to calculate the

COVER STORYChargemaster item price less than hospital outpatient prospectivepayment system ambulatory payment classification rateChargemaster item price is 0Chargemaster item description is “miscellaneous”Chargemaster item description/price is editable onlineBILLING/CLAIM SUBMISSIONHIPAA-compliant electronic claim submission rateFinal-billed/claim-not-submitted backlogMedicare supplement insurance billing followingadjudicationNon-Medicare coordination-of-benefits priority-2insurance billing following COB-1 paymentMedicare return-to-provider denials rateOutsourced guarantor statement cost toproduce/mailDENIALS0000Standard100% 1 A/R day 2 business days 2 business days 3%THIRD-PARTY AND GUARANTOR FOLLOW-UP20-25 centsStandardInsurance A/R aged more than 90 days from 15%-20%service/dischargeInsurance A/R aged more than 180 days from service/discharge 5%Insurance A/R aged more than 365 days from service/discharge 2% 3%Bad-debt write-offs as a percentage of gross revenue 3%Charity write-offs as a percentage of gross revenueCost-to-collect ([patient access patient financial services 3% agency expenses] cash) 100%Patient cash as a percentage of net revenue average length of stayIn-house A/R daysDNFB A/R days (includes late charge hold 5-6 A/R daysperiod HIM “DRG development”) 55 A/R daysNet A/R days 100%Patient cash as a percentage of cash goal 2%Total point-of-service cash as a percentage of cash goalCASHIERING, REFUNDS, ADJUSTED POSTINGStandardOverall denials rateClinical denials rateTechnical denials rateUnderpayments additional collection rateAppeals overturned rateElectronic eligibility ratePhysician precertification double-check rateCase managers’ time spent securing authorizations rateTotal denial reason codes 4% 5% 3% 75%40%-60% 75%100% 20% 25CUSTOMER SERVICEStandardCorrespondence backlogWalk-in patients’ wait timeAutomatic call distribution system average hold timeACD system abandoned call percentage of callson hold 30 secondsACD system percentage of calls resolvedin 5 minutesACD system percentage of calls not resolvedin 10 minutesCalls resolved in unit, without complaint/referralto director of patient financial services 1 business day 5 minutes 2 minutes 2% 85% 5% 95%COLLECTIONS/OUTSOURCING VENDORSStandardBad debt netback ([collections – fees] placements) percentageBad debt fee percentageThird-party extended business office fee percentageSelf-pay extended business office fee percentageLegal collections fee percentageMedicaid eligibility assistance fee A-compliant electronic payment posting percentage100% 1 business dayTransaction posting backlog (during the month)Transaction posting backlog (end of the month)0 business days 2 A/R daysCredit-balance A/R days (gross) due dateMedicare credit-balance report submission timelinessfraction of accounts accepted by payers’ computerswithout being intercepted by your compliance scrubbing system or being cleaned by a biller. When yourfront-end operations are achieving best practiceresults, this indicator will rise accordingly.Collection agency netback percentage. Would you paymore to get better results? Most organizations would,and that is why netback is the only valid measure ofoutsourced vendor performance. In a situation wheretwo vendors split your business, this measurementcan put them on an equal footing, even if their feerates are different.Net revenue. You have to know this number because itis the divisor of so many other indicators. This is thekey indicator that can answer the CFO’s question,“Why are collections off this month?” Whenreplying, it helps to know that net revenue was downtwo months ago, for example.Case mix index. This is one of the hidden influencersof collections. Your case mix, particularly related todiagnosis-related group pairs, can dramaticallyinfluence colections, independent of other factors inrevenue cycle operations. If case mix declines, cashfalls, and vice versa. Again, it helps to answer thequestion, “What is happening with collections?” It ishelpful to know, for example, that your highestadmitting cardiac surgeon was on vacation for threeweeks during the previous month.hfmJULY 20057

COVER STORYMORE VIEWS ONIMPROVEMENTStrategies for Improving theRevenue Cycle: IndustryViews provides insight intohow financial executives areimplementing measurableperformance improvementsin their revenue cycle.Go to www.hfma.org/resource/400417.pdfComplaints to administration. Don’t make the mistakeof thinking that this indicator should be zero. If yourcollections aren’t assertive enough to generate a fewcalls to administration each month, you may be leavingtoo much for your collection agencies. It is a good ideato categorize complaints to identify root causes. Youwant to fix broken processes while remaining true toyour prime objective: collecting cash. This is one ofthe areas where you can truly see that revenue cyclemanagement is an optimizing function.Total open accounts. This is a very good secondaryindicator. Usually, less is more. If, however, you haverecently changed recurring outpatient account policies to discharge and readmit every month, thisnumber will increase for a while. This indicatorshould be analyzed in comparison with the number ofnew accounts generated each month. If your collection cycle averages 60 days, you should have roughlytwo months’ worth of open accounts on your books.An Organizational PerspectiveIncreasingly, CFOs are realizing the importance ofgiving revenue cycle leaders a chance to presentperformance indicator results to key organizationalconstituencies. The chief revenue officer and/orrevenue cycle management team should be invited topresent to the finance committee, or at least to theirpeers, every quarter at a minimum to explain therevenue cycle concept, illustrate important trends,and highlight new occurrences. Organizations thathave already elevated the revenue cycle position tothe level of senior management are ahead of thegame in understanding and disseminating thenumbers and trends that tell the story of the organization’s health. It’s important for all employees to becognizant of their roles and responsibilities asmembers of the wider revenue cycle team.Certainly, having the numbers alone is not enough.When coupled with a good understanding of industrystandards and the process management skillsneeded to help achieve them, your numbers can tell astory of financial wellness, complete with key indicators that are trended across time.Remember: How do you know where you’re going ifyou don’t know where you’ve been?About the authorDavid C. Hammer, FHFMAis vice president, revenue cycle solutions,McKesson Provider Technologies, FortLauderdale, Fla., and a member of HFMA’sFlorida Chapter. Questions or commentsabout this article may be sent to him atdavid.hammer@mckesson.com.Reprinted from the July 2005 issue of Healthcare Financial Management.Copyright 2005 by Healthcare Financial Management Association, Two Westbrook Corporate Center, Suite 700, Westchester, IL 60154.For reprint information, call 1-800 -252-HFMA.8JULY 2005healthcare financial management

may often subdivide each performance indicator by hfm JULY 2005 3 GLOSSARY OF REVENUE CYCLE KEY PERFORMANCE INDICATORS Key indicators can be divided into hierarchies, or first-, second-, and third-level indicators. Most of these indicators should be relative indica-tors, i.e., they should illustrate a ratio or other arithmetical relationship .

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