Claims analytics healthcare vendors sell to hospitals is a platform with dashboards over millions of claims. Healthcare claims analytics for a practice with one to ten providers is six figures from one month's claims register, computed by hand or on the free claims cycle worksheet on this site, and read the same way every month. The figures are the denial rate, the clean-claim rate, the net and gross collection rates, days in accounts receivable and the average charge per claim. This page sets out where each one comes from on the register, what a change in it means for the practice, and what a biller does about it, without a benchmark, because a benchmark that is not the practice's own last month is a number to argue with rather than act on.
The denial rate and the clean-claim rate: the pair the biller can move
The denial rate is the month's denied claims over the claims submitted; the clean-claim rate is the claims paid on first submission over the same total. They move together, and they move when the front end changes: eligibility checked, the authorisation on the claim, the modifiers on the timed codes, the referring provider enrolled. The register with the reason codes says which denials are producing the rate, and last month's CO 16s and CO 96s are the list of what to fix.
The collection rates: whether the billing is working or the contract is
The gross collection rate divides payments by charges as billed, and it mostly measures the fee schedule. The net collection rate divides payments by charges less contractual adjustments, which is the money the practice could have collected, and it measures the billing: a net rate that falls while the denial rate is flat is money leaking at the patient balance or the appeal. The two together tell the practice whether to look at its billing or at its contracts.
Days in A/R: what the other figures do to cash
Days in accounts receivable divides the outstanding balance at month end by the average daily charge, and it says how many days of billing are sitting unpaid. It rises when denials are worked late, when EOBs are posted late, and when patient statements go out late; it falls when the register is worked weekly. Claims pending an attachment under CO 252 sit inside it, which is why the register has to show them as denials rather than as submitted.
Reading the figures month on month, and what to keep
The figures mean something only against the practice's own earlier months, which is why the register keeps each month's figures with its date. A denial rate that fell after the front desk started checking eligibility is a practice learning; a days-in-A/R figure that rose after a biller left is a practice about to have a cash problem. The claims cycle worksheet here computes the month; Eobify Pro keeps the months side by side. The filing limit, 12 months from the date of service for Medicare, is the horizon every outstanding claim in the A/R figure ages against.
Questions people ask about claims analytics healthcare
What is claims analytics in healthcare for a small practice?
Six figures from the month's claims register: denial rate, clean-claim rate, net and gross collection rates, days in A/R and the average charge per claim, read against the practice's own earlier months.
Which claims analytics figure matters most?
The denial rate, because it is the one the practice can change fastest and its reason codes say how. Days in A/R is what the denial rate does to cash over a quarter.
Do I need analytics software for healthcare claims analytics?
Not at one to ten providers. The six figures come from the month's counts and totals, which the worksheet on this site computes; the register that keeps them month on month is the only software the practice needs for it.
Should I compare my figures with a published benchmark?
Only with care. Benchmarks are averaged across specialties and payer mixes that are not yours. Your own last month is the comparison that says whether the billing improved.