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1
Claims & Denial Management
6 pts
Claim denial rate is consistently below 5%
MGMA 2025: Top performers <5% denial rate
+1
First-pass clean claim rate is 95% or above
HFMA 2025: Best-in-class ≥95% first-pass rate
+1
Denial root-cause analysis conducted monthly
Categorize by payer and code type
+1
All appeals filed within payer timely-filing limits
Missing deadlines = permanent revenue loss
+1
Denial overturn rate tracked and above 50%
MGMA: High performers overturn >60% of appeals
+1
Zero-pay and underpayment claims are auto-flagged
HFMA: underpayments avg 3–5% of net revenue
+1
2
Front-End Eligibility & Intake
5 pts
Insurance eligibility verified before every appointment
Real-time verification reduces front-end denials by up to 30%
+1
Patient demographics validated at registration
Incorrect DOB/member ID = auto-denial
+1
Prior authorizations obtained and documented
Missing auth = #1 avoidable denial category
+1
Copays and deductibles collected at point of service
MGMA: Best practices collect >90% at POS
+1
Coordination of Benefits confirmed for dual-coverage patients
COB errors create significant underpayment risk
+1
3
Coding Accuracy & Compliance
6 pts
Coding audits conducted at minimum quarterly
AAPC Guidelines 2025: quarterly = best practice
+1
E/M leveling is consistent with documentation
Under-coding = revenue loss; over-coding = audit risk
+1
Modifier usage reviewed for accuracy regularly
Incorrect modifiers = denials + compliance exposure
+1
ICD-10 codes verified to highest specificity
Unspecified codes trigger payer scrutiny
+1
Unbundling and upcoding risks assessed regularly
OIG actively targets both — quarterly review essential
+1
NCCI edits applied before claim submission
CMS NCCI edits prevent bundling-related rejections
+1
4
A/R Management & Cash Flow
6 pts
Days in A/R is consistently below 30 days
MGMA 2025: Top quartile <30 days; avg = 35–45
+1
A/R aging over 90 days is below 15% of total A/R
RevCycleIntelligence: <40% recovery chance past 90 days
+1
Net collection rate is 97% or above
MGMA 2025: Top performers collect ≥97% of collectible revenue
+1
Write-off rate reviewed and justified monthly
Unexplained write-offs mask systemic denial problems
+1
Payer-specific payment posting reconciled daily
Delayed posting distorts A/R reporting accuracy
+1
Patient balance follow-up process is documented
Patient A/R growing? Needs a dedicated workflow
+1
5
Reporting & KPI Visibility
5 pts
Real-time KPI dashboard accessible to leadership
HFMA 2025: Live visibility = 20%+ faster issue resolution
+1
Monthly financials reviewed within 10 business days
Delayed reviews let leaks compound undetected
+1
Payer contract rates loaded and tracked in PM system
Without it, underpayments go undetected for months
+1
Charge capture lag monitored (target: same-day)
Delays in charge entry = delayed cash flow
+1
MGMA/HFMA benchmark comparison done annually
Knowing your rank drives targeted improvement
+1
6
Credentialing & Payer Enrollment
5 pts
All providers credentialed with all active payers
Billing without credentials = 100% rejection rate
+1
Credentialing expiration dates tracked proactively
Lapses can retroactively void paid claims
+1
New provider enrollment initiated 90+ days before start
Average enrollment: 60–120 days per payer
+1
Medicare and Medicaid revalidation calendar maintained
Missed revalidation = billing suspension
+1
Delegated credentialing agreements reviewed with MCOs
Reduces time-to-bill for HMO/PPO networks
+1
Your Performance Tier
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Your Progress
1
Claims & Denial Mgmt
0/6
2
Front-End Eligibility
0/5
3
Coding & Compliance
0/6
4
A/R Management
0/6
5
KPI Visibility
0/5
6
Credentialing
0/5
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