* Is High or Low Best: Higher is Better
Benefit Accuracy Rate measures the percentage of instances where the health insurance company communicated the appropriate patient responsibility amount (i.e., co-pay, deductible, or co-insurance amounts) to the healthcare provider, based on the services rendered and the benefits that the patient is eligible for under their insurance policy. A high rate of incorrect patient responsibility information has a significant negative impact on both health plan member experience/service levels, as well as the service being provided to the healthcare provider (e.g., doctor, clinic, hospital, etc.). Errors here can also impact employee productivity and rework rates within claims operations, as additional payments may have to be collected from customers (or paid out to customers) following the communication of an incorrect patient responsibility amount. To remedy inaccuracies here, look to pre-adjudicate claims (and/or adjudicate them in real-time) to estimate patient responsibility, or implement more rigorous methods for verifying patient eligibility.
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 time of service divided by the total number of claims processed by the payer over the same period of time, as a percentage.
Two numbers are used to calculate this KPI: (1) the number of instances where the health insurance payer returned the correct patient responsibility amount to the healthcare provider following the completion of medical services, and (2) the total number of times where the payer communicated a patient responsibility amount to a healthcare provider over the same time period. The patient responsibility amount is the dollar amount beyond what is covered by the patient’s insurance plan that must be paid out-of-pocket (or the co-pay) by the patient. Any instance where this amount does not match the amount that SHOULD have been paid (including any amount above or below the correct amount), as defined by the eligibility and current status of the patient’s insurance plan, should not be counted in the numerator for this calculation.
(Number of Instances where Correct Patient Responsibility Amount was Communicated by Payer / Total Number of Patient Responsibility Amounts Communicated) * 100
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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