* Is High or Low Best: Higher is Better
Contacted Fee Schedule Match Rate is a metric developed and monitored by the American Medical Association (AMA) to measure the percentage claims paid out by insurance payers that match the amount in the healthcare fee schedule that they publish for use by healthcare providers. These fee schedules are used to estimate how much patients will owe (i.e., patient responsibility amount), and how much insurance companies will pay out to healthcare providers, for various medical services. Various issues can arise when the actual and contracted fee amounts do not match: disputes between patients and healthcare providers, delinquent or hard-to-collect medical bills, administrative work/rework caused by over or under-payments, and disputes between healthcare providers and insurers are potential consequences of fee schedule mismatches.
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 claims payments made 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’s fee for medical services rendered by a healthcare provider matched the contracted fee schedule, and (2) the total number of medical claims filed with the health insurance payer over the same period of time. Any instance where the payer covered the total amount in the contracted medical services fee schedule (i.e., the fee schedule that was agreed upon by the contracted healthcare provider), or any amount over that, was covered by the insurance payer should be counted in the numerator for this calculation. The denominator should include each claim filed by healthcare providers (e.g., doctors, pharmacies, clinics, etc.) with the insurance payer(s) being examined during the measurement period.
(Number of Claims Payments Matching Fee Schedule / Total Number of Claims Payments) * 100
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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