Practices and physician's constantly struggle with understanding how well their billing is working. This can be difficult to do because reliable medical billing benchmarks that can be easily applied are difficult to find. A great solution to this is the use of a Theoretical Yield (i.e., the amount you should collect for every dollar billed if your billing is working perfectly).
Understanding the concept of yield is the key behind assessing the billing performance using medical billing benchmarks. From a medical billing standpoint, yield is the amount of a claim that should actually result in a payment versus a contractual adjustment. In other words, if your yield is 50%, then on a $100 claim you should received $50 in payments and will write-off the rest to contractual adjustments. In the first article in the series on allowables I discussed why you should set your fee schedule higher than your contractual allowables. Having fees higher than allowables is what results in yields that are less than 100%.
Calculating your practice's yield is straightforward. At its simplest level you take the allowable for a CPT and divide by the fee you charge for that CPT. Using the example above, if your fee for a given CPT is $100 and your allowable for that fee is $50, then your yield is $50 (what you should collect)/$100 (what you charge) = 50%.
This is a straightforward calculation. The complication arises because of the various payer contracts for a practice and the fact that the yield for a specific payer often varies by CPT (i.e., with BCBS you may have a yield of 50% for one CPT and 60% for another CPT).
This means that calculating your yield requires you to understand your procedure mix. To get a close estimate of your yield for a specific payer you can:
- Take your top 20 CPT codes and calculate the yield for each of these codes; and then
- Calculate a weighted average for the overall yield based upon the frequency of each of your CPTs;
To move from a close estimate to a more precise estimate your repeat the above procedure but instead of only using your top 20 CPT codes, you use as many as is required to cover at least 90% of your charge volume with each payer. Typically, however, the top 20 CPTs provide an accurate answer.
Once you have completed the above exercise for one payer, you need to repeat this for each of your top payers (you should do this for the payers that represent at least 80% of your payment volume). Once you have done this you can then get an overall yield for your practice by creating a weighted average yield for the practice based upon your charge volume (not payment volume) for the practice. The idea of a weighted average yield of the practice works well as long as your procedure mix and payer mix are stable. If either changes significantly, then you need to recalculate your yields.
With a weighted average practice yield (or Theoretical Yield) in hand you can easily get an initial understanding of how well you medical billing is performing. This medical billing benchmark will provide significant insight into your true performance. If your practice theoretical yield is 50% and your actual performance is 42% - then you are leaving a lot of money uncollected (up to 8% of every dollar billed). There are a number of items that will keep you from achieving your full Theoretical Yield, but you certainly would expect to be within a few percentage points.
Although developing yields can be tedious work, it is critical to know your practice's yield and use this medical billing benchmark to understand if your medical billing is working well.
About ClaimCare, Inc.
ClaimCare Medical Billing Services stands out from the crowd of medical billing companies. ClaimCare offers a complete medical billing solution, has the only service level guarantee in the industry, offers best-of-breed technology, an air tight medical billing process, actionable reporting and broad experience and can work on its clients' medical billing systems. For more information contact ClaimCare Medical Billing Services by email at email@example.com , by phone at (877) 440-3044 or visit the ClaimCare Medical Billing Company website.
Copyright 2009, Carl Mays II and the ClaimCare Medical Billing Company