Health Insurance KPIs, Metrics & Benchmarks

KPIs & Metrics to Measure and Manage Health Plan Performance

Health Plans

What are Health Insurance KPIs?

The focus of health insurance metrics and Key Performance Indicators (KPIs) is measuring the effectiveness and efficiency of a health insurance company’s ability to deliver health plan benefits to its customers. Often this includes different processes, such as member on-boarding, member services, new business processing, provider network management and claims processing.

Using Health Insurance Metrics to Manage Department Performance

Health insurance operations include three major aspects: provider network development and management, claims processing and member services. Effective service for both plan members and healthcare providers (doctors, clinics, pharmacies, etc.) is vital to the growth of any health plan. KPIs for health insurance companies measure the effectiveness of the company’s provider network, the level of service provided to its members and operational efficiency in areas such as claims and member services.

KPI's & Data 

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Health Insurance Benchmarking Report

This 62-page benchmarking report includes benchmarking data for 22 health insurance operations KPIs including Claim Settlement Cycle Time, Revenue per Health Plan Member and more. Each KPI i...

Type : Benchmarking Report Bundle

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New Member Enrollment Accuracy Rate

The number of accurate new member health plan enrollments completed (i.e., enrollments that do not have errors, or missing information/documentation) divided by the total number of enrollmen...

KPI Type : Quality

Formula : (Accurate New Member Enrollments / Total Enrollments Processed) * 100

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The Top 5 Metrics for Health Insurance Companies

Health insurance companies in the United States are required to invest a certain percentage of premiums earned back into the business to improve operations and quality of care. KPIs and metrics can help to identify areas where the health plan can improve operations and customer experience. Here are 5 common health plan KPIs:

  1. 1.Medical Loss Ratio (MLR)
  2. 2.Claim Settlement Cycle Time (Medical)
  3. 3.Claims Denial Rate
  4. 4.Provider Contracting Cycle Time
  5. 5.First Contact Resolution Rate (Member Services)

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KPI's & Data 

int(1)
Health Insurance Benchmarking Report

This 62-page benchmarking report includes benchmarking data for 22 health insurance operations KPIs including Claim Settlement Cycle Time, Revenue per Health Plan Member and more. Each KPI i...

Type : Benchmarking Report Bundle

KPI's & Data 

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New Member Enrollment Accuracy Rate

The number of accurate new member health plan enrollments completed (i.e., enrollments that do not have errors, or missing information/documentation) divided by the total number of enrollmen...

KPI Type : Quality

Formula : (Accurate New Member Enrollments / Total Enrollments Processed) * 100

KPI Benchmark Range : Buy this instant download data-as-a-service product to find out now!

KPI's & Data 

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Health Insurance KPI Encyclopedia

This document defines over 200 Health Insurance industry KPIs, including metric definitions for Member Services, New Business Processing, Claims Processing and more. These KPIs are further c...

Type : KPI Encyclopedia

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Cost per Claim (Medical)

The total cost (salary, benefits, other overhead) of processing medical claims divided by the number of medical claims processed (includes all incoming claims, regardless of whether or not t...

KPI Type : Cost

Formula : Total Medical Insurance Claim Processing Expense / Total Number of Medical Claims Processed

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KPI's & Data 

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Percentage of New Member ID Cards Received On-Time

The number of ID cards for new health plan members that were received on or before the effective date divided by the total number of new member ID cards sent over the same period of time, as...

KPI Type : Service

Formula : (Number of New Member ID Cards Received On-Time / Total Number of New Member ID Cards Sent) * 100

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KPI's & Data 

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New Member Enrollment (Manual) Cycle Time

The number of business days required to manually (non-electronic) enroll a new member or policyholder into a health plan, from the point-of-sale until the new member is enrolled into the hea...

KPI Type : Service

Formula : (Sum of New Member Manual Enrollment Times) / Total Number of New Member Manual Enrollments

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KPI's & Data 

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New Member Enrollment (Electronic) Cycle Time

The number of calendar days required to electronically enroll a new member or policyholder into a health plan, from the point-of-sale until the new member is enrolled into the health plan th...

KPI Type : Service

Formula : (Sum of New Member Electronic Enrollment Times) / Total Number of New Member Electronic Enrollments

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KPI's & Data 

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Percentage of Member ID Card Renewals Received On-Time

The number of renewed ID cards for existing health plan members that were received on or before the effective date divided by the total number of renewed ID cards sent over the same period o...

KPI Type : Service

Formula : (Number of Renewed Member ID Cards Received On-Time / Total Number of Renewed Member ID Cards Sent) * 100

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KPI's & Data 

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ERA Accuracy Rate

The total number of initial electronic remittance advice (ERA) claim denial or adjustment messages provided by the insurance company that include accurate adjustment messages and/or denial r...

KPI Type : Quality

Formula : (Number of Accurate Initial ERA Messages Sent / Total Number of Initial ERA Messages Sent) * 100

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KPI's & Data 

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Percentage of Claims Completed Within 15 Days

The number of medical insurance claims adjudicated within 15 days of receiving the claim from the healthcare provider divided by the total number of claims adjudicated by the payer over the...

KPI Type : Service

Formula : (Number of Medical Claims Adjudicated within 15 Days / Total Number of Medical Claims Adjudicated) * 100

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KPI's & Data 

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Percentage of Claim Lines Paid $0

The total number of claims that were filed by healthcare providers, but for which the payer paid $0 due to disclosed and/or undisclosed claim edits (i.e., changes to claims reimbursement rul...

KPI Type : Quality

Formula : (Number of Medical Claims Lines Paid $0 / Total Number of Medical Claims Lines Submitted) * 100

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KPI's & Data 

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Health Plan Members per Employee

The total number of health plan members, or policyholders, covered by the health insurance provider divided by the total number of employees working for the insurer (company-wide) at the sam...

KPI Type : Quality

Formula : Total Number of Health Plan Policyholders / Total Number of Employees

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KPI's & Data 

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Claim Settlement Cycle Time (Medical)

The average number of days required to process, adjudicate and pay out a single approved medical insurance claim, measured from the time that the claims is submitted by the healthcare provid...

KPI Type : Service

Formula : (Sum of Medical Claims Settlement Cycle Times) / Number of Medical Claims Settled

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KPI's & Data 

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Revenue per Health Plan Member

The amount of total revenue generated by the health insurance company over a certain period of time divided by the average number of health plan members, or policyholders, covered by the com...

KPI Type : Revenue

Formula : Total Revenue / Total Number of Health Plan Policyholders

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Benefit Accuracy Rate

The number of patient responsibilities for health insurance claims in which the payer returned the correct patient responsibility information (based on patient benefits eligibility) at the t...

KPI Type : Quality

Formula : (Number of Instances where Correct Patient Responsibility Amount was Communicated by Payer / Total Number of Patient Responsibility Amounts Communicated) * 100

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Claims Auto-Adjudication Rate

The total number of claims that are automatically adjudicated (i.e., those approved or denied automatically without need for manual intervention) divided by the total number of claims adjudi...

KPI Type : Quality

Formula : (Number of Claims Auto-Adjudicated / Total Number of Claims Adjudicated) * 100

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Contracted Fee Schedule Match Rate

The number claim payments matching the insurer's contracted fee schedule (i.e., the medical service/procedure fee schedule published by the insurance payer) divided by the total number of cl...

KPI Type : Service

Formula : (Number of Claims Payments Matching Fee Schedule / Total Number of Claims Payments) * 100

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Claims First Pass Resolution Rate

The total number of claims resolved on the initial submission (i.e., paid or transferred to patient responsibility) divided by the total number of claims adjudicated over the same period of...

KPI Type : Quality

Formula : (Number of Medical Claims Resolved on Initial Submission / Total Number of Medical Claims Adjudicated) * 100

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KPI's & Data 

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ERA Transparency Rate

The total number of electronic remittance advice (ERA) claim denial or adjustment messages provided by the insurance company that include clear, actionable items and explanations divided by...

KPI Type : Quality

Formula : (Number of ERA Denial or Adjustment Messages Including Clear Reasons and Action Items / Total Number of ERA Denial or Adjustment Messages Sent) * 100

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KPI's & Data 

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Provider Enrollment Request Cycle Time

The average number of days required for a health insurance company, or payer, to process a request from a healthcare provider for enrollment into their provider network, from the time the re...

KPI Type : Service

Formula : (Sum of Provider Enrollment Request Cycle Times) / Total Number of Provider Enrollments Completed

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KPI's & Data 

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Patient Eligibility Accuracy Rate

The number of instances where the patient eligibility information initially returned by the health insurance company matched the final outcome of claim adjudication divided by the total numb...

KPI Type : Quality

Formula : (Number of Accurate Patient Eligibility Transactions / Total Number of Medical Claims Adjudicated) * 100

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KPI's & Data 

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Percentage of Charges Transferred

The dollar amount of healthcare expenses (e.g., co-insurance, deductibles, or other non-covered medical services) that are transferred from the primary insurer to the next responsible party...

KPI Type : Service

Formula : (Dollar Amount of Healthcare Costs Transferred to Next Responsible Party / Total Dollar Amount of Claims Submitted for Adjudication) * 100

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KPI's & Data 

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Medical Loss Ratio (MLR)

The total amount (in dollars) of claims, and other expenses that improve quality of care, paid to members and healthcare providers by the insurance company over a certain period of time divi...

KPI Type : Cost

Formula : (Total Claims Paid Out + Expenses Devoted to Quality of Care Improvements) / Total Premium Earned) * 100

KPI Benchmark Range : Buy this instant download data-as-a-service product to find out now!

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KPI's & Data 

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Health Insurance KPI and Metrics Encyclopedia

This document defines a list of over 200 Health Insurance industry KPIs, including metric definitions for Health Plan Operations, Member Services, New Business Processing, Claims Processing,...

Type : KPI Encyclopedia

KPI's & Data 

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Claims Denial Rate (Medical/Health)

The number of medical/health insurance claims filed by policyholders that are denied by the insurance company divided by the total number of medical/health claims processed by the payer over...

KPI Type : Quality

Formula : (Number of Medical Claims Denials / Total Number of Medical Claims Adjudicated) * 100

KPI Benchmark Range : Buy this instant download data-as-a-service product to find out now!

KPI's & Data 

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Prior Authorization Rate

The number of medical services rendered by in-network providers that require prior authorization (i.e., explicit approval from the insurance payer prior to the initiation of the service; or...

KPI Type : Service

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Percentage of Claims Requiring Rework

The total number of medical claims submitted to the insurance company that require rework (e.g., error correction, etc.) prior to adjudication divided the total number of medical claims adju...

KPI Type : Service

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Average Hold Time by Call Reason: Eligibility Inquiry

The average amount of time that customers inquiring about their health plan coverage wait on hold during calls over a certain period of time.

KPI Type : Service

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Average Hold Time by Call Reason: Issue Escalation

The average amount of time that customers wait on hold during calls that were escalations, issues which required "escalation" to a manager or supervisor, over a certain period of time.

KPI Type : Service

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KPI's & Data 

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Average Hold Time by Call Reason: Financial Assistance Program

The average amount of time that customers inquiring about the health plan financial assistance program eligibility and coverage wait on hold during calls over a certain period of time.

KPI Type : Service

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