* Is High or Low Best: Higher is Better
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.).
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.
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.
(Number of Accurate Patient Eligibility Transactions / Total Number of Medical Claims Adjudicated) * 100
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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