Jul 28, 2024
Apr 15, 2025
Written By Elizabeth Cifers
Every industry uses metrics to determine how it’s performing compared to its peers, known as benchmarks, including retina.
If you’re within the retina industry benchmark, everything is typically okay. But if you’re an outlier, you must understand why, which is where Key Performance Indicators (KPIs) are handy.
Being an outlier does not automatically mean a problem, but it’s wise to explore the information. Your KPIs are internal metrics that provide insight into your retina practice’s success.
Numerous KPIs provide information concerning the health of the revenue cycle. Understanding the metric and its meaning to your retina clinic is indispensable. Fortunately, being a sub-specialty does not significantly affect the following revenue cycle KPIs that occasionally get forgotten or overlooked:
These four metrics can tell you a lot about what is happening with the revenue cycle of your retina practice.
This KPI indicates the charge capture efficiency at your retina clinic, which affects the Total Days in Accounts Receivable (A/R) ratio. The definition is the days between the service and charge entry dates. The industry benchmark is one to three days.
Since the service date starts the clock for the insurance company, always run your reports by the service date.
There are a few ways you can experience charge entry lag at your retina practice:
If the charge entry lag is greater than three days, assess the cause. Review the charge entry lag metric for each if you have multiple providers who enter their charges at your retina clinic. As a composite, all the providers may appear to contribute to the higher number. Still, one provider may skew the actual results for this KPI.
If staff at your retina practice work remotely, reviewing the best-streamlined option is even more critical to ensure entering the charges is within the benchmark. Each day the charge goes unentered, another day is added to the A/R.
This KPI is related to charge entry lag but is slightly different. The billed charge lag occurs when the provider enters the charges, but the charges don’t get sent to the clearinghouse. The metric indicates the efficiency in charge capture at your retina practice and will affect the Total Days in A/R ratio.
The benchmark for the billed charge lag is one to three days.
If the metric for your retina clinic is higher than three days, determine why.
Possible reasons may include a charge entry or a biller being out of the office and no one taking their place. Or, even though you are on an EHR system, you use a ‘charge slip,’ and getting those from a satellite office can be challenging, and it will increase your metric and increase your days in A/R.
If your retina practice has multiple providers and locations, run the charge entry lag for each provider and each site. You may find one provider delinquent in completing chart documentation, getting the charge slips to the billers, contributing to the lag, or a combination.
There are many permutations to the possibilities affecting this KPI.
The charge entry and billed charge lag KPIs are within the retina practice’s and providers’ control. Improving these two metrics can affect the timeliness of receiving payments from insurance companies—which is something you want, right?
In medical billing, the clean claim rate KPI is the number of claims that pass the edits the first time without correction. The clean claim rate calculation is the number of claims passing the edits divided by the number of claims submitted at your retina clinic.
The clean claim rate benchmark is 95% or better.
There are errors if your percentage is lower than 95%. Review the reports from your clearinghouse to discover the issues stopping the claim from going to the insurer. For example, the date of birth or spelling of the name might be incorrect, or it doesn’t match what the insurer has on file. Review the clearinghouse report and check the remittance advice remark and reason codes to find the cause of the error(s).
Educating staff at your retina practice about mistakes to prevent reoccurrences is crucial.
The claim denial rate KPI in medical billing is the percentage of claims denied by the payer for a specific period. To calculate the claim denial rate for your retina clinic, you divide the number of denied claims by the number of submitted claims for the same period. The period can be any time frame, e.g., a month, a quarter, or a year. The key is to use the same start and end dates for this metric. 5% is the preferred target, but on average your claim denial rate should be 5–10%.
It is critical to look at claim denials in two ways:
Reviewing the claim denial rate KPI as dollars may lead to meeting the benchmark percentage at your retina practice if the dollar amount is low. However, you may find another benchmark if you check the claim denial rate KPI as a percentage of claims submitted.
For example, the claim denial rate at a given retina clinic based on the count of denied claims is 7%. However, based on dollars, the claim denial rate KPI is 13%, which is unacceptable.
Another example is a denial count of 13%, but the dollars denied are 5%. There could be a few high-dollar claims or many low-dollar claims. If you review one calculation, you may or may not have a problem, but you generate a better picture of the denied claims if you look at both. Ultimately, both analyses are vital to the success of your retina practice.
KPIs are indispensable for evaluating the revenue cycle at your retina practice. Without them, you won’t be able to tell what’s happening with your practice’s revenue cycle… which I think you’ll agree isn’t great. But, using these four metrics can tell you much about what is happening with the revenue cycle.
Are you looking to optimize your retina practice? I can help. Don’t hesitate to get in touch. Please book your free consultation call with me today here.
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