ClaimOps / Quality and service levels
Section 07What you control, what you influence, and what you can only observe
The most common cause of a soured revenue cycle engagement is a service level that holds the provider to an outcome it cannot move. This framework separates the three categories, and the composite index is built from the controllable ones only.
| Category | Metric | Standard | Consequence |
|---|---|---|---|
| Controllable | Coding accuracy, line level | ≥ 96.0% | Directly service-levelled |
| Controllable | Charge entry accuracy | ≥ 99.0% | Directly service-levelled |
| Controllable | Payment posting accuracy | ≥ 99.0% | Directly service-levelled |
| Controllable | Turnaround compliance across all queues | ≥ 97.0% | Directly service-levelled |
| Controllable | AR touch documentation completeness | ≥ 97.0% | Directly service-levelled |
| Controllable | Roster adherence and seat occupancy | ≥ 95.0% | Directly service-levelled |
| Influenceable | Clean claim rate, first pass | ≥ 95.0% | Tracked; joint action plan on breach |
| Influenceable | First-pass resolution rate | ≥ 92.0% | Tracked; joint action plan on breach |
| Influenceable | Denial rate | ≤ 6.0% | Tracked; root cause split by owner |
| Observable | Days in accounts receivable | ≤ 38 days | Reported, never service-levelled |
| Observable | AR over 90 days as a share of total | ≤ 18.0% | Reported, never service-levelled |
| Observable | Net collection rate | ≥ 95.0% | Reported, never service-levelled |
The composite quality index
The composite decides whether the performance benchmark in the commercial terms is met. It is built from controllable metrics only, its calculation is published in advance, and it does not change mid-month.
| Component | Weight | Floor | Measured from |
|---|---|---|---|
| Coding accuracy, line level | 35% | 96.0% | Audit sample, pre-bill |
| Charge entry and payment posting accuracy | 20% | 99.0% | Audit sample, pre-bill |
| Turnaround compliance across all queues | 20% | 97.0% | System timestamps, all items |
| AR touch documentation completeness | 15% | 97.0% | Audit sample |
| Roster adherence and seat occupancy | 10% | 95.0% | Seat register against roster |
| Composite index | 100% | 95.0 | For the full rate |
Audit design
Every new agent is audited at 100% of output until two consecutive weeks at or above the accuracy floor, then at 20%, then at the steady-state sample.
| Stage | Sample | Auditor | Release gate |
|---|---|---|---|
| Certification, pre go-live | 100% of the test set | Akontec, moderated | 96% or above to touch live data |
| Weeks 1–2 live | 100% of output, pre-bill | Provider quality analyst | No claim released without audit |
| Weeks 3–6 | 20% random, pre-bill | Provider quality analyst | Two clean weeks to step down |
| Steady state — coding | 5% per agent per week, minimum 10 items | Provider quality analyst | Monthly calibration with Akontec |
| Steady state — entry and posting | 3% per agent per week, minimum 10 items | Provider quality analyst | Monthly calibration with Akontec |
| Monthly re-audit | 10% of the provider's own audited sample | Akontec | Divergence above 3 points voids the internal score |
Error classification
An error is critical if it would change the amount billed, the amount the payer paid, or the compliance position of the claim. Everything else is non-critical.
| Class | Examples | Scoring | Action |
|---|---|---|---|
| Critical | Code not supported by documentation; wrong modifier changing reimbursement; wrong payer; posting to the wrong account; missed timely-filing window | Full weight; a single critical error fails the audited item outright | Same-day correction, root cause within 48 hours, agent re-audited at 100% for two weeks |
| Non-critical | Incomplete touch note; wrong reason code on an otherwise correct action; formatting or sequencing that does not change the outcome | Partial weight | Coached at team-leader level, trended weekly |
| Client-caused | Ambiguous or missing documentation; instruction later reversed; system unavailability | Excluded from the provider score | Logged and reported to the client in the monthly pack |
Review rhythm
Daily
A production file lands with Akontec by 10:00 IST covering the prior United States day: volume completed by queue, volume pending, turnaround breaches with reasons, blockers, and absent seats against the roster. It is a file, not a narrative, and it is the same file every day.
Weekly
A thirty-minute call between the two delivery managers: the week's scorecard, the open-query log, the backfill position and anything trending.
Monthly
A formal pack and review — the full scorecard, the calibration result, the seat register reconciled to the invoice, the risk log and next month's plan. This is the meeting at which a service credit, if any, is confirmed.
Quarterly
Commercial and capacity review with the account managers: expansion decision, control audit and the rate position for the following period.
Next step
A scorecard whose calculation is published in advance and does not change mid-month.
That is one of the things we do promise. The full list — and the longer list of things we will not promise — is in the partner FAQ.
Read the partner FAQ See the onboarding plan