KPI Benchmarks : Percentage of Charges Transferred
- Benchmark Range
- Benchmark Average
- Benchmark Sample Size (n) 365
* Is High or Low Best: Lower is Better
Percentage of Charges Transferred
Percentage of Charges Transferred measures the amount of medical costs that the health insurance company transfers to the next responsible party for further collections (i.e., the primary health insurer deems that they are not responsible for paying this portion of the expenses, placing additional burden on healthcare providers to collect those funds from another party). When medical charges are transferred in this manner, it causes a significant amount of additional work (i.e., collecting from next responsible party) for healthcare providers (e.g., doctors, hospitals, etc.), which can diminish relationships with both providers and, in some cases, policyholders who may be held responsible for additional charges.
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 at the time of adjudication divided by the total liability amount sought by healthcare providers over the same time period, as a percentage.
KPI Best Practices
- Disclose changes in claims policies to healthcare providers
- Clear, adequate and consistent communication between payer and providers
- Consistent use of pre-authorization and screening where required
KPI Calculation Instructions Percentage of Charges Transferred?
Two numbers are used to calculate this KPI: (1) the dollar amount of healthcare costs (submitted for payment by healthcare providers) that the insurance payer transfers to the next responsible party, and (2) the total dollar amount of claims submitted to the insurer for adjudication over the same period of time. The amount transferred to the next responsible party should include the dollar amount of medical charges that the health insurance company deems they are not responsible for paying and must be collected from another party (e.g., another health insurance company, healthcare provider or policyholder, etc.). The total dollar amount of claims submitted for adjudication includes the amount submitted by healthcare providers for payment, regardless of whether it is paid or not by the insurance company. Do not count dollar amounts related to duplicate claims submissions, or resubmissions, in this calculation.
KPI Formula :
(Dollar Amount of Healthcare Costs Transferred to Next Responsible Party / Total Dollar Amount of Claims Submitted for Adjudication) * 100
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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