Percentage of Claim Lines Paid $0

Percentage of Claim Lines Paid $0

KPI Details

The Percentage of Claim Lines Paid $0 measures the volume of individual medical claim line items that the insurance company did not pay out (partially or fully) to the submitting healthcare provider due to changes in claims reimbursement policies, relative to the total number of claims lines processed during the measurement period. Changes to claims reimbursement policies, disclosed or undisclosed, that impact claims payments to healthcare providers can lead to disputes between providers and health insurance companies, as well as between providers and policyholders/customers. These disputes drive higher administrative costs, diminish customer service levels, and reduce organizational capacity for both health insurance payers and healthcare providers.

KPI Definition

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 rules) divided by the total number of claims lines filed over the same period of time, as a percentage.

KPI Best Practices

• Pre-authorization requirements clearlycommunicated and enforced
• Frequently audit and update medical codes used for billing
• Claim edits proactively sent to providers on a frequent basis

KPI Calculation Instructions Percentage of Claim Lines Paid $0?

Two numbers are used to calculate this KPI: (1) the number of claims line items submitted for processing that were reduced to $0 (i.e., the payer did not cover any expense for that item) due to a disclosed or undisclosed change in reimbursement policy, and (2) the total number of individual medical claim line items processed by the payer over the same period of time. Include in the numerator for this calculation any insurance claim line item that, due to a disclosed (i.e., providers were made aware of the change in policy) or undisclosed (i.e., providers were NOT made aware of the change in policy) change in the payer’s claims reimbursement policy. A single medical insurance claim may include many lines, which may or may not be covered under the policyholder’s insurance plan (i.e., line items may be paid for in-full, partially or not at all by the insurance payer).

KPI Formula :

(Number of Medical Claims Lines Paid $0 / Total Number of Medical Claims Lines Submitted) * 100