"Every line is the perfect length if you don't measure it."                                                                

 - Marty Rubin

In Measuring Staff Performance - Part I, we reviewed the importance of metrics in staff development efforts.  We stated five categories of staff measurement, three of which we will review today.

• Clean Claim Rates
• Denials
• Claim Velocity
• Payment Velocity
• Follow-up Success

Clean Claim Rates.  John Wesley, said, "cleanliness is indeed next to godliness."  In the RCM world, truer words were never spoken.  A clean claim is defined by Medicare as "a claim which has no defect, impropriety or special circumstance, including incomplete documentation that delays timely payment."

Medical bills will be denied if elements necessary for payment processing are missing. The required elements must be complete, legible and accurate, and as such, can be quantified.  Each of the following can be expressed as a ratio, or percentage of total claims.  Specifically, we assess the following:

• Raw claim output.  Accounting for manual data entry vs. electronic import, how many claims per day/week/month is this team member completing?  Granted, this metric doesn't measure accuracy, but it's a starting point.
• Pre-pass errors. Most practice management systems will look for claim errors prior to actually creating the claim.  Comparing the pre-pass error rates will help you determine the quality of your initial data entry.  Note!  If you are getting data electronically via your EHR, this could be an indication of problems at the source.
• Clearinghouse errors.  Your clearinghouse will have its own set of edits that will stop claims from reaching the payor.  Knowing your stats will help you identify systemic issues that need attention.
• Payor edits (error rejections). These are edits typically unique to the payor and keep your claim from entering the payor's adjudication process.  Unlike denials, these claims are not even considered.

If you really want to dig deep, parse the above by reason for failure (coding, typing errors, missing data elements, etc.).

Denials.  Your electronic 835 remittance advice is chock full of valuable data - if your software can make use of it.  Track both denial and remark codes and look for trends or systemic problems.

Claim Velocity.  Claim velocity statistics measure the number of days in each step of the process and help determine where the bottlenecks are, and where there may be significant opportunity for improvement.

• DOS to intake.  On average, how long is the period from DOS to arrival at the billing office?
• Intake to filing.  Once received by the billing office, how long does it take for a claim to leave the building?
• DOS to filing.  DOS to intake + Intake to filing.
• DOS to Remittance.  DOS to intake + Intake to filing + filing to remittance advice.

In Measuring Staff Performance - Part III, we will examine Payment Velocity and Follow-up Success rates.

‍