Number of healthcare claims settled per FTE that performs the process group "adjudicate claims and process reimbursement"

This measure calculates number of healthcare claims settled (i.e., approved and paid) per full-time equivalent employee (FTE) that performs the process group "adjudicate claims and process reimbursement". The Process group "adjudicate claims and process reimbursement" includes [Developing claim/encounter informatics, adjudicating claims, processing intake of claims, performing claim policy management, communicating claim outcomes, performing benefits management, preparing and processing claims, processing reimbursement and notification, and managing other party liabilities.]. This Staff Productivity measure is intended to help companies assess the efficiency of their staff related to the process group "Adjudicate claims and process reimbursement".

Benchmark Data

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Measure Category:
Staff Productivity
Measure ID:
105669
Total Sample Size:
109 All Companies
Performers:
25th Median 75th
- 8,750 -
Key Performance Indicator:
No
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Compute this Measure

Units for this measure are claims.

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Number of healthcare claims settled / (Number of internal FTEs that perform the process group "adjudicate claims and process reimbursement" + Number of external FTEs that perform the process group "adjudicate claims and process reimbursement")

Key Terms

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To calculate the number of full-time equivalents employed during the year for each respective process or activity, you must prorate the number of employees and the hours spent performing each process/activity. Assume that a full-time worker represents 40 hours per week. Provide the average number of full-time equivalents employed during the year for each respective process. Include full-time employees, part-time employees, and temporary workers hired during peak demand periods. Allocate only the portion of the employee's time that relates to or supports the activities identified for an applicable process. Prorate management and secretarial time by estimating the level of effort in support of each activity, by process.

For example, a part-time secretary in the finance department for XYZ, Inc. charges all of his time to finance department activities. He works 20 hours per week. The secretary splits his time evenly supporting employees working in the general accounting process and the financial reporting process. Thus, his time should be allocated by process. So, if he works throughout the year and supports these two processes, his time would be split evenly as:

20hrs/40hrs = .5FTE * 50% for general accounting = .25FTE for general accounting

20hrs/40hrs = .5FTE * 50% for financial reporting = .25FTE for financial reporting

Staff Productivity is a measure of the efficiency of individuals performing specific processes. Measures in staff productivity generally relate the transaction volume or outcome of the process with the effort in terms of full time equivalent employees to perform the process.

Measure Scope

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Health Insurance Payor (7.2.1)

  • 5.3.1 - Develop claim/encounter informatics (17187)
    • 5.3.1.1 - Manage and report on claim processing activity (17188)
    • 5.3.1.2 - Manage quality assurance and auditing procedures (17189)
    • 5.3.1.3 - Manage critical inquiry process and appeals (17190)
  • 5.3.2 - Adjudicate claims (17191)
    • 5.3.2.1 - Determine coverage/benefits (17192)
    • 5.3.2.2 - Perform clinical editing (17193)
    • 5.3.2.3 - Determine covered service (17194)
    • 5.3.2.4 - Determine eligibility (17195)
  • 5.3.3 - Process intake of claims (17196)
    • 5.3.3.1 - Enter paper claims into claims system (17197)
    • 5.3.3.2 - Enter OCR claims into claims system (17198)
    • 5.3.3.3 - Enter electronic claims into claims system (17199)
    • 5.3.3.4 - Enter interactive claims into claims system (17200)
    • 5.3.3.5 - Create claims imaging and record within claims system (17201)
    • 5.3.3.6 - Assign claim control ID (17202)
    • 5.3.3.7 - Route claims for processing (17203)
    • 5.3.3.8 - Conduct pre-edit claims examination (17204)
    • 5.3.3.9 - Validate claims (17205)
  • 5.3.4 - Perform claim policy management (17206)
    • 5.3.4.1 - Develop claim policy rules (17207)
    • 5.3.4.2 - Monitor claim policy (17208)
    • 5.3.4.3 - Review claim policy appeal (17209)
  • 5.3.5 - Communicate claim outcomes (17210)
    • 5.3.5.1 - Generate remittance advise (17211)
    • 5.3.5.2 - Generate explanation of benefits (17212)
  • 5.3.6 - Perform benefits management (17213)
    • 5.3.6.1 - Provide benefits support (17214)
    • 5.3.6.2 - Provide benefits administration (17215)
  • 5.3.7 - Prepare and process claims (17216)
  • 5.3.8 - Process reimbursement and notification (17217)
  • 5.3.9 - Manage other party liabilities (17218)