Part 3: Payment Integrity KPIs and Reporting Strategies

Written by Monique Pierce, Head of Payment Solutions at Cohere Health

There is significant variation in how payment integrity (PI) programs define and report success. In this blog, we’ll review key performance indicators (KPIs) by PI program and a reporting strategy that has proven very effective. Whether your PI program is centralized or decentralized, evolving or mature, this content is meant to offer guidance and spark discussion as we embark on the standardization journey together.

Payment integrity metrics

KPIs require a solid foundation of metrics, and it is essential to build specific metrics and reports/dashboards based on type and purpose. Here are recommendations for how to categorize PI metrics:

1. Operational metrics (Inventory, Production, Quality)
2. Financial metrics (Cost, Savings)
3. Performance metrics (Staff, Program)

Operational metrics

Operation metrics help you manage the work. Inventory, production, and quality headers include a distinct set of metrics with a specific purpose.

• Inventory metrics include volume, status, and aging. Trending these values overall and by status and status reason over time helps ensure adherence to regulatory requirements/policy and provides insight for staffing and forecast projections. However, these are point-in-time metrics, rendering them an inappropriate source for outcome reporting.

• Production metrics include counts, turnaround time (TAT), dollars, and percentages. They capture counts, TAT, percentage results, and dollars for a specific period (daily, weekly, monthly, etc.). These outcome or result metrics can be applied to each key process within a program (Selection, Records, Review, Letters, Dispute, Recovery (avoidance for prepay).
  
  Counting each key action, calculating the TAT, and summing savings dollars provide necessary data for projections and identifying areas of opportunity. Production metrics are foundational for measuring staff, program, and process performance improvement. 

• Quality metrics include counts, status, and percentages. Knowing how many reviews or disputes have been completed is not enough–one must also understand the percentage of work QA’d and the error rate. These metrics often have regulatory or SLA requirements. They are used for staff evaluation and provide insight into areas of opportunity for program performance improvement.

Financial metrics

Financial metrics describe the cost and benefit of the work completed due to payment integrity activity. A finance team will typically ask PI leaders to track staff and vendor costs and final savings dollars associated with the work, while they track other fixed-cost expenses.

• Savings metrics include counts, dollars, and dollars/ID reporting. Most programs prioritize these metrics.

Dollars are represented in three categories based on where in the life cycle the savings occur:

• Via post-pay programs (recovery)
• Via prepay programs (avoidance)
• Before the claim is received (prevention)

• Cost metrics include administrative, staff, BPO, vendor contingency, and per audit. They track the direct cost of the PI activity and are used to identify opportunities and calculate ROI.

Performance metrics

KPIs allow leaders to measure or evaluate the performance of a process or program. They are typically a more complex metric, requiring a calculation or comparison of two or more metrics over time to normalize the data.

• Staff KPIs include productivity (action/time, audits/ hour), quality% (errors/reviews), and TAT to monitor effective inventory management.
• Program KPIs include the same productivity, quality, and TAT at the program level.

Some claim audit KPI examples include:

• Average # audits/hour
• % Accurate review
• % Medical records received
• % Audits with an error/ overpayment identified (finding or hit rate)
• % Disputes and % disputes overturned
• Average # of days to recover

Performance metrics also incorporate financial metrics to produce total savings, savings/audit, and ROI (comparison of savings and costs), and member and claim metrics, such as total eligible members, total claim count, and total medical expense, to create savings as a % of medical expense and savings PMPM.

While many KPIs are program agnostic, some programs or solutions have unique KPIs to measure and monitor unique processes. Below are suggested KPIs for seven high-level solutions/program types.