Glossary · KPIs
Glossary · KPIsDenial Rate
The percentage of submitted claims initially rejected by the payer before any rework or appeals.
Definition
Denial Rate.
The percentage of submitted claims initially rejected by the payer before any rework or appeals.
Formula
(Denied claims ÷ Total submitted claims) × 100
Industry benchmark
Healthy ambulatory: under 5%. Specialties with heavy prior auth (oncology, behavioral health): under 8%.
Sources
Primary references for this entry.
- HFMA Denial benchmarks.
- CAQH CORE denial reporting standards.
Related terms
Other terms in KPIs.
- KPIs
Clean Claim Rate
The percentage of claims accepted by the payer on first submission without rework. The single most-cited revenue cycle KPI for measuring billing operation quality.
Open entry - KPIs
Cost to Collect
The total operating expense required to collect each dollar of patient revenue, including billing salaries, software, denial-rework labor, and outsourced vendor fees.
Open entry - KPIs
Days in A/R
A measure of how long, on average, it takes a practice to collect payment after the date of service. The primary cash-flow KPI in revenue cycle management.
Open entry - KPIs
First-Pass Resolution Rate
The percentage of claims that resolve to a final disposition (paid or written off) without any post-submission rework. Stricter than clean-claim rate, which only measures initial acceptance.
Open entry - KPIs
Gross Collection Rate
Total payments collected as a percentage of total billed charges. A weak quality indicator on its own because it depends on chargemaster pricing.
Open entry - KPIs
Net Collection Rate
Collected revenue as a percentage of allowed amount, after contractual adjustments. The most rigorous measure of revenue-cycle effectiveness because it strips out chargemaster pricing.
Open entry
Frequently asked
About Denial Rate.
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