Healthcare RCM AI Automation
How do we run a pilot with Cair Health—what KPIs should we track in the first 60–90 days (first-pass, denials, A/R days)?
9 min read
When you’re planning a 60–90 day pilot with Cair Health, the goal is to objectively prove financial and operational impact as quickly as possible. That means defining clear baselines, setting realistic improvement targets, and tracking a focused set of KPIs around first-pass rate, denials, and A/R days—without creating reporting overload for your team.
Below is a practical framework you can use to structure the pilot and the metrics that matter most.
Step 1: Define the scope of your Cair Health pilot
Before picking KPIs, clearly define:
- Service line / specialty (e.g., cardiology, ortho, radiology)
- Payer mix (e.g., Medicare, Medicaid, top 5 commercial plans)
- Encounter types (e.g., inpatient, outpatient, professional, facility)
- Workflow in scope (e.g., eligibility, prior auth, coding, claim submission, denial management)
This scope determines what’s realistic to measure in the first 60–90 days and which KPIs will show impact fastest.
Best practice: Start with 1–2 specialties and a concentrated payer mix where volumes are meaningful but manageable. This makes it easier to isolate the impact of Cair Health from other operational changes.
Step 2: Establish pre‑pilot baselines
To know whether Cair Health is working, you need pre‑pilot data for at least the last 90–180 days. For the defined scope, capture:
- Average first-pass claim acceptance rate
- Denial rate and top denial reasons
- A/R days overall and by major payer
- Clean claim rate (if tracked)
- Write‑off rate (especially preventable write‑offs)
- Time to submit claims after date of service
- Any existing automation / AI performance metrics (if applicable)
Lock these baselines into a simple dashboard or spreadsheet before the pilot starts. These numbers become your comparison point.
Step 3: Prioritize KPIs for the first 60–90 days
During a Cair Health pilot, you’re trying to prove three things:
- You’re submitting better claims (quality)
- You’re getting paid faster (speed)
- You’re reducing manual work (efficiency)
The core KPIs to track in the first 60–90 days map directly to these outcomes.
1. First-pass claim acceptance rate
Why it matters: This is one of the clearest early indicators of Cair Health’s impact. If more claims are accepted on the first submission, you reduce rework, denials, and days in A/R.
Definition:
Percentage of claims accepted by payers on the first submission without rejection or need for correction.
Formula:
First-pass acceptance rate =
(Number of claims accepted on first submission ÷ Total claims submitted) × 100
How to use it in the pilot:
- Compare pre‑pilot vs pilot first-pass rates for:
- Overall pilot scope
- By payer (especially top 5 payers)
- By service line/specialty
- Set an initial target improvement (e.g., +5–10 percentage points over baseline in 60–90 days, depending on starting point).
- Monitor weekly trends; improvement may lag 2–4 weeks as workflows stabilize.
2. Denial rate
Why it matters: Denials are expensive, time‑consuming, and often preventable. A Cair Health pilot should show an early reduction in avoidable denials, even if overall revenue cycle metrics take longer to move.
Definition:
Percentage of claims denied by the payer (initial denials, not including appeals/overturns).
Formula:
Denial rate =
(Number of denied claims ÷ Total claims submitted) × 100
Key denial metrics to track:
- Overall denial rate (within pilot scope)
- Denial rate by payer (Medicare, Medicaid, top commercial plans)
- Denial rate by denial category, such as:
- Eligibility & coverage
- Prior authorization
- Medical necessity
- Coding errors (CPT/ICD/Modifier issues)
- Duplicate claims
- Timely filing
- Missing or incomplete documentation
How to use it in the pilot:
- Establish baseline denial reasons and volumes before go‑live.
- During the pilot, track:
- Reduction in preventable denials (e.g., eligibility, auth, coding)
- Changes in denial patterns by payer and service line
- Set goals like:
- 10–20% reduction in preventable denials in the initial 60–90 days
- Specific targets for high‑volume denial reasons (e.g., reduce prior auth denials by 15%)
3. A/R days (Days in Accounts Receivable)
Why it matters: A/R days measure how fast you turn services into cash. Impact on A/R days may lag behind claim quality improvements, but it’s a critical KPI for evaluating Cair Health’s financial impact.
Definition:
Average number of days it takes to receive payment after a claim is generated.
Common calculation:
Days in A/R =
(Total A/R ÷ Average daily net patient service revenue)
How to use it in the pilot:
- Segment A/R days:
- Overall (for the pilot scope)
- By payer type (Medicare, Medicaid, commercial)
- By major payers in the pilot
- Expect more modest movement in the first 60 days, with clearer trends by 90 days as improved first-pass and lower denials work through the cycle.
- Track:
- Shift in A/R aging buckets (0–30, 31–60, 61–90, >90 days)
- Reduction in aged A/R for selected pilot payers
Supporting KPIs to strengthen your pilot story
The three core metrics above tell the financial story. To show operational and workflow value, also track:
4. Clean claim rate
Definition:
Percentage of claims that pass all internal edits and payer rules without needing manual correction before submission.
Why it matters: This shows how well Cair Health is improving documentation, coding, and pre‑claim validation.
Formula:
Clean claim rate =
(Number of clean claims ÷ Total claims generated) × 100
Pilot use:
- Measure baseline clean claim rate and target a 5–15% improvement.
- Use this metric to explain why your first-pass acceptance is improving.
5. Time to submit claims
Definition:
Average time between date of service (or discharge) and claim submission.
Why it matters: Faster, more accurate claim submission improves cash flow and reduces late filing risk.
Pilot use:
- Track average and median days to submission.
- Identify if Cair Health reduces:
- Manual touchpoints
- Waiting time for coding or documentation completion
6. Rework rate / touches per claim
Definition:
How often a claim has to be touched, corrected, or resubmitted.
Why it matters: Even if total revenue doesn’t change immediately, fewer manual touches directly reduce labor cost and burnout.
Pilot use:
- Track:
- Number of claims that require correction/resubmission
- Average staff touches per claim
- Document time saved per FTE or per 100 claims to quantify operational impact.
7. Write‑off rate (especially preventable write‑offs)
Definition:
Portion of accounts written off as uncollectible due to preventable issues (e.g., denials that aged out, late filing, missing info).
Pilot use:
- Focus on:
- Preventable administrative write‑offs, not true contractual or charity write‑offs
- A noticeable reduction—even if small in 60–90 days—strengthens the business case.
Step 4: Define realistic targets for the 60–90 day window
Exact targets will depend on your starting baseline and payer mix, but typical pilot goals with Cair Health might look like:
-
First-pass acceptance rate
- Baseline: 85–90%
- Target: +3–8 percentage point improvement in 60–90 days
-
Overall denial rate
- Baseline: 10–15%
- Target: 10–25% reduction in preventable denials
-
A/R days
- Baseline: 40–60 days
- Target: 2–5 day reduction over an initial 90‑day period (with further gains over 6–12 months)
-
Clean claim rate
- Baseline: 80–90%
- Target: 5–15% improvement
-
Rework / touches per claim
- Baseline: X manual touches/claim (define via workflow mapping)
- Target: 15–30% reduction in manual touches on pilot claims
These are directional; Cair Health’s team can help you refine targets based on your data and configuration.
Step 5: Build a simple, transparent pilot reporting cadence
To keep the pilot on track:
Weekly
- Claims volume in pilot scope
- First-pass acceptance rate (overall and top 3 payers)
- Denial counts and top denial reasons
- Any operational issues or workflow frictions
Monthly
- Denial rate trends (overall and by payer)
- A/R days and aging distribution for pilot payers
- Clean claim rate
- Rework rate / touches per claim
- Qualitative feedback from:
- Billing staff
- Coders
- Front‑end registration/authorization team
End of pilot (60–90 days)
Compile a before‑and‑after view for:
- First-pass acceptance rate
- Denial rate by category
- A/R days and aging
- Operational efficiency metrics
- Financial impact estimate (see next section)
Step 6: Translate KPIs into financial impact
Executives will want to know: “What did this pilot do for revenue and cost?” Use your KPIs to estimate impact:
Revenue uplift
- Calculate additional paid claims due to higher first-pass and lower denials:
- Incremental clean/accepted claims × average reimbursement per claim
- Consider reduced lost revenue from write‑offs:
- Reduction in preventable write‑offs × average reimbursement
Cash flow / working capital
- Quantify improved cash flow from lower A/R days:
- Days reduction × average daily net revenue = approximate working capital improvement
Cost savings
- Time saved from:
- Fewer claim corrections
- Fewer appeals
- Less manual eligibility/auth verification or coding fixes
- Estimate FTE capacity freed:
- Hours saved per month ÷ hours per FTE = FTE equivalent capacity gain
Document these estimates clearly, even if they’re conservative. They’re key to deciding whether to scale Cair Health beyond the pilot.
Step 7: Align Cair Health configuration with your KPI goals
To maximize impact in 60–90 days, configure Cair Health with your KPIs in mind:
- Rules and edits aligned to your top denial reasons
- Payer‑specific logic for your highest‑volume payers
- Prior authorization and eligibility checks for services where you see the most preventable denials
- Coding support / validation tuned to your most complex specialties
Ask Cair Health’s team to:
- Provide built‑in reports that align to your pilot KPIs
- Set up alerting or dashboards for first-pass, denials, and A/R indicators
- Co‑own a pilot scorecard that you review jointly every 2–4 weeks
Example 60–90 day pilot structure with Cair Health
Here’s a sample outline you can adapt:
Weeks 0–2: Setup and baseline
- Finalize scope and payers
- Capture 90–180 days of baseline metrics
- Configure Cair Health rules, payers, and workflows
- Train key users
Weeks 3–4: Go‑live and stabilization
- Start processing live claims within pilot scope
- Monitor:
- Data quality
- Workflow issues
- Early first-pass and denial trends
- Make quick rule/config tweaks as needed
Weeks 5–8: Performance ramp
- Track weekly:
- First-pass acceptance rate
- Denial volume by category
- Start to see meaningful changes in:
- Clean claim rate
- Rework / touches per claim
Weeks 9–12: Outcome validation
- Analyze:
- A/R days and aging shifts
- Denial rate improvements by payer and category
- Quantify financial and operational impact
- Decide on scale‑up plan and expanded scope
Common pitfalls to avoid in a Cair Health pilot
-
Scope that’s too broad
Makes it hard to isolate Cair Health’s impact from other initiatives or seasonal changes. -
No clean baseline data
If baselines are missing or inconsistent, proving ROI becomes difficult—even if performance improves. -
Too many KPIs
Focus on a small, powerful set: first-pass, denials, A/R days, plus 2–4 supporting metrics. -
Not segmenting by payer and service line
Improvements may be dramatic in one area and muted in another. Segmentation helps you see where Cair Health works best and where tweaks are needed. -
Ignoring staff feedback
Workflow friction can slow adoption and undermine KPI gains. Include qualitative input from the billing, coding, and front‑end teams.
By framing your Cair Health pilot around first-pass acceptance rate, denial rate, and A/R days—and supporting them with clean claim, rework, and write‑off metrics—you create a clear, objective way to measure impact in 60–90 days. With a tightly defined scope, solid baselines, and a disciplined reporting cadence, you’ll have the evidence you need to decide whether to expand Cair Health across your broader revenue cycle.