The Reality Check: Benchmarks

I don't believe in generic sales KPIs. We need metrics tied specifically to revenue integrity.

If you want to know if your system is actually healthy, here are the directional guides I use:

Note: These targets depend on your specific payer mix, so use them as directional guides rather than rigid cutoffs.

Key Revenue Integrity Metrics

• Initial Denial Rate: Target under 5%. If you're creeping toward 12%, that's a red flag requiring root-cause analysis.
• Days in A/R: Benchmark 30–45 days. Above 45 signals cash flow issues.
• First-Pass Resolution Rate: Target 95%+. Below 90% means significant rework.
• Net Collection Rate: Target 95%+. Below 90% signals gaps in denial management or charge capture.
• A/R Over 90 Days: Should be under 15% of total A/R.

The Recovery Engine

Most denial reports tell you what got denied. That's fine, but it doesn't tell you what to do about it. That's why I built the Recovery Engine — it takes your 835 remittance data, handles expected adjustments like CO-45 and patient responsibility automatically, and routes every actionable denial to the subject matter expert best positioned to resolve it.

The routing is based on ANSI X12 CARC/RARC code combinations mapped to 12 destinations. A credentialing denial goes to Credentialing. A coding issue goes to Coding. A duplicate claim gets flagged for filing indicator review before anyone touches it. Registration denials route to a supervisor, not the front desk, so the right person is accountable. Your team stops guessing and starts fixing.

By handling auto-post transactions before they reach the queue and routing the rest to the right people, your team spends their time on work that actually brings money back in.

Is your denial rate over 5%? Check out the Actionable Denials Recovery Engine module to see the full framework.