Patient Eligibility Accuracy Rate

Patient Eligibility Accuracy Rate

KPI Details

Patient Eligibility Accuracy Rate measures the overall quality and accuracy of the patient eligibility information provided to healthcare providers by insurance companies regarding medical services to be provided to patients. A high accuracy rate here is important, because it allows healthcare providers to identify and resolve any eligibility-related issues prior to performing the medical service, or prior to submitting the claim to the payer for processing (i.e., avoiding a denial or additional rework). A higher than desired rate of inaccurate patient eligibility information can greatly diminish customer service levels, lead to rework and reduced capacity within the claims function (and for administrative functions within healthcare providers), and may lead to costly disputes with healthcare providers (e.g., doctors, hospitals, etc.).

KPI Definition

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 number of claims adjudicated by the insurance company over the same period of time, as a percentage.

KPI Best Practices

• Up-to-date systems for transfer of information between providers and payers
• Validate patient eligibility information prior to submission to providers
• Disclose changes in claims policies to healthcare providers

KPI Calculation Instructions Patient Eligibility Accuracy Rate?

Two numbers are used to calculate this KPI: (1) the number of instances where the patient eligibility information (e.g., patient eligible for services, patient ineligible for services, patient not found, eligibility information not available, coordination of benefits denial, etc.) initially returned by the health insurance company matched the final outcome of claim adjudication, and (2) the total number of claims adjudicated by the insurance company over the same period of time. An accurate patient eligibility transaction should be counted (in the numerator for this calculation) as any instance where the healthcare provider was provided with an initial patient eligibility outcome from the insurance company that matched the actual outcome following formal claims adjudication.

KPI Formula :

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