Key Performance Indicators (KPIs) are used to measure how an organization or department is performing. Companies often evaluate and analyze their business processes against industry standards to see if there is room for improvement.

With the help of industry leaders, the Healthcare Financial Management Association (HFMA) has comprised a list of MAP Keys – 29 KPIs that set the industry standard for the performance of the revenue cycle within all types of healthcare organizations. These MAP Keys are separated into 5 major groups, Patient Access, Pre-Billing, Claims, Account Resolution, and Financial Management.

Within the Claims group is the Clean Claim Rate (CCR). The HFMA defines CCR as the number of claims that pass edits requiring no manual intervention divided by the number of claims accepted into the claims processing tool for billing.

Why is Clean Claim Rate Important?

CCR is the metric that encompasses the performance of most of the revenue cycle process. It shows providers the quality of information collected and how much manual effort is going into editing claims. The higher the CCR, the less time and money it takes for a provider to receive payment. The industry standard for CCR is ≥ 95%, which can be difficult to achieve without the right RCM processes.

Increasing Clean Claim Rate

The most effective way to increase CCR is by partnering with an RCM vendor that offers solutions to address and correct errors while establishing the root cause of the error. For example, Data-Core Healthcare’s Denial Management Solution analyzes claims and payment data to predict the probability of denial based on established rules and past denials. The solution flags these claims and provides the most likely reason for denial. This decreases the amount of time it takes to edit the necessary fields thus speeding up the claim submission to the payer.

How to Get Started

It is never too late to put effort towards increasing CCR. Follow these few steps for your organization to see the benefits of a high CCR:

1.      Evaluate your current CCR

2.      Set goals

3.      Assess your top errors to identify areas for improvement

4.      Analyze CCR data over specified intervals

5.      Build and communicate a plan to resolve CCR issues

There are other ways to measure the effectiveness of a billing process, however, CCR is the metric that encompasses the most important aspects of the revenue cycle such as data quality and need for manual intervention. While the changing payer regulations will require the tweaking of RCM processes regularly, the right people, tools, and processes will lead to decreased denials and increased reimbursement.