====== SharpInsight — Analytics & Reporting Guide ======

SharpInsight is ClaimRev's analytics and reporting module. It provides 40+ reports across payment analysis, revenue cycle, denial management, payer intelligence, coding compliance, claims analysis, and MIPS quality tracking.

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===== Getting Started =====

  - Navigate to **SharpInsight** from the main menu
  - The landing page shows all available report categories based on your account features
  - Use the **sidebar** on the left to switch between reports (click the collapse button to maximize the report area)
  - Use the **search box** at the top of the sidebar to filter reports by name
  - Click the **info icon** on any report to see a summary, metric definitions, and tips

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===== Payment Analysis =====

Reports for tracking payment patterns, detecting underpayments, and measuring time-to-payment.

==== Payment Variance ====

Compares what was charged versus what was actually paid across payers and time periods. Use this report to spot payers that consistently underpay or overpay relative to billed amounts.

**Key Metrics:**
^ Metric ^ Description ^
| Yield | The percentage of billed charges that were actually collected. A yield of 85% means $0.85 was paid for every $1.00 charged. |
| Total Charged | The sum of all line-item charge amounts submitted to the payer. |
| Total Paid | The sum of all payments received from the payer. |
| Variance | The dollar difference between charged and paid amounts. Negative variance means underpayment. |

**Tips:**
  * Sort by Yield to find the lowest-performing payers quickly.
  * Use the drill-down to see individual payment events behind each payer row.

==== Underpayment Detection ====

Identifies service lines where the payer paid less than the contracted or expected rate. Helps recover revenue that was legitimately owed but not fully paid.

**Key Metrics:**
^ Metric ^ Description ^
| Contracted Amount | The expected payment based on your contracted rate with the payer for that procedure code. |
| Variance from Contract | The difference between the contracted amount and what was actually paid. Negative values indicate underpayment. |
| Underpaid Count | The number of service lines where actual payment fell below the contracted rate. |

**Tips:**
  * Focus on payers with the highest total underpayment amounts for maximum recovery potential.
  * This report requires contracted rates to be configured in the **Contracted Rates** screen.

==== Days to Payment ====

Measures how long it takes from claim submission to receiving payment. Tracks turnaround time by payer to identify slow-paying payers and monitor cash flow patterns.

**Key Metrics:**
^ Metric ^ Description ^
| Avg Days | The average number of calendar days between claim submission and ERA receipt. |
| Median Days | The middle value when all payment times are sorted. Less affected by outliers than the average. |
| Min / Max Days | The fastest and slowest payment turnaround times observed. |

**Tips:**
  * Compare Average vs Median — a large gap suggests a few very slow payments are skewing the average.
  * Payers consistently exceeding 30 days may warrant follow-up or contract review.

==== MIPS Payment Impact ====

Detects MIPS payment adjustments (CARC 237) in your ERA data. Shows the total dollar impact of CMS penalties or bonuses, broken down by provider and over time.

**Key Metrics:**
^ Metric ^ Description ^
| Total Adjustment | The sum of all CARC 237 adjustment amounts. Negative = penalties; positive = bonuses. |
| Affected Service Lines | The number of service lines that received a MIPS-related adjustment (CARC 237). |
| Avg Adjustment per Line | The average dollar adjustment per affected service line. |
| Estimated Annual Impact | Projects the selected period's adjustments to a full 12-month estimate. |

**Tips:**
  * If you see penalties here, the **MIPS Quality** module can help you track and improve quality reporting to reduce future adjustments.
  * MIPS bonuses appear as positive adjustments — use the Provider Scorecard in MIPS Quality to maximize these.

==== Regulatory Penalties ====

Detects non-MIPS regulatory penalties (CARC 237) in your ERA data, such as NEMA XR-29 CT dose reporting non-compliance.

**Key Metrics:**
^ Metric ^ Description ^
| Total Penalties | The sum of all non-MIPS CARC 237 adjustment amounts deducted from your Medicare payments. |
| Penalty Types | Breakdown by remark code showing which regulatory requirements are causing penalties (e.g., N759 for NEMA CT dose reporting). |
| Affected Service Lines | The number of service lines that received a regulatory penalty adjustment. |
| Estimated Annual Impact | Projects the selected period's penalties to a full 12-month estimate. |

**Tips:**
  * Check the remark code in the Penalty Types table to identify the specific CMS requirement causing the deduction.
  * These penalties are separate from MIPS — see the **MIPS Payment Impact** report for MIPS-specific adjustments.

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===== Revenue Cycle =====

Reports for monitoring revenue leakage, A/R aging, charge lag, and clean claim rates.

==== Revenue Leakage ====

Provides a high-level view of where revenue is being lost in the billing cycle. Compares total billed amounts against collections and breaks down losses by category.

**Key Metrics:**
^ Metric ^ Description ^
| Collection Rate | Total collected divided by total billed, as a percentage. Represents your overall revenue capture efficiency. |
| Contractual Adjustments | Expected write-downs based on payer contracts (the difference between billed charges and allowed amounts). |
| Denials & Write-Offs | Revenue lost to claim denials and uncollectable amounts beyond contractual adjustments. |
| Leakage by Category | Breaks down lost revenue into Denied (full denials) and PartialPay (underpayments). |

**Tips:**
  * A collection rate below 50% typically indicates significant issues with either payer mix, denial rates, or underpayments.
  * Compare this report month-over-month to track whether revenue cycle improvements are having an impact.

==== A/R Aging ====

Shows the age distribution of outstanding accounts receivable. Identifies how long claims have been waiting for payment.

**Key Metrics:**
^ Metric ^ Description ^
| Aging Bucket | Time ranges (0-30, 31-60, 61-90, 91-120, 120+ days) grouping claims by how long they've been outstanding. |
| Outstanding Amount | The total dollar amount of unpaid claims in each aging bucket. |
| Percentage | Each bucket's share of total outstanding A/R. |

**Tips:**
  * Healthy A/R should have the majority of balances in the 0-30 day bucket.
  * Claims aging past 90 days are at high risk of becoming uncollectable — prioritize follow-up on these first.

==== Charge Lag ====

Measures the time between when a service is performed and when the claim is submitted. Long charge lag delays cash flow and can result in timely filing denials.

**Key Metrics:**
^ Metric ^ Description ^
| Lag Bucket | Time ranges grouping claims by the number of days between service date and submission date. |
| Claim Count | The number of claims falling into each lag bucket. |
| Cumulative % | The running total percentage — shows what percent of claims are submitted within each timeframe. |

**Tips:**
  * Most payers require claims within 90-180 days of service. Claims lagging beyond that risk timely filing denials.
  * Target 95%+ of claims submitted within 7 days of service for optimal cash flow.

==== Clean Claim Rate ====

Tracks the percentage of claims accepted by the payer on first submission without rejections or errors.

**Key Metrics:**
^ Metric ^ Description ^
| Clean Claim Rate | The percentage of claims accepted on first submission. Industry benchmark is 95%+. |
| Total Submitted | The number of claims sent to payers in the selected period. |
| First Pass Accepted | Claims that were accepted without rejection or error on the initial submission. |

**Tips:**
  * Rates below 90% indicate systemic issues in claim preparation that should be addressed.
  * Review by payer to identify if specific payer requirements are being missed consistently.

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===== Denial Management =====

<WRAP center round info 90%>
Don't see this section? Contact ClaimRev to have denial management reporting enabled for your account.
</WRAP>

Reports for tracking denial work item outcomes, biller productivity, appeal success rates, and write-off trends.

==== Biller Productivity ====

Measures denial work item throughput per user. Shows how many items each biller worked, resolved, and the revenue recovered through their efforts.

**Key Metrics:**
^ Metric ^ Description ^
| Items Assigned | The number of denial work items assigned to this user within the selected date range. |
| Resolved | Items that reached a terminal status (Appeal Won/Lost, Written Off, Rebilled, Paid, or Closed). |
| Resolution Rate | The percentage of assigned items that were resolved. Higher rates indicate faster throughput. |
| Recovered | Total dollars recovered through successful appeals or rebilled claims. |
| Written Off | Total dollars written off as uncollectable. |
| Avg Days to Resolve | The average number of days from work item creation to resolution. |
| Notes Added | Total notes added by this user across all work items — a measure of documentation effort. |

**Tips:**
  * Compare Resolution Rate across billers to identify who may need additional training or support.
  * High Recovered amounts relative to Denial Amount indicate effective appeal and rebilling strategies.
  * Use the monthly trend to track whether team productivity is improving over time.

==== Denial Root Cause ====

Breaks down denials by CARC (Claim Adjustment Reason Code) to reveal the most common reasons claims are denied.

**Key Metrics:**
^ Metric ^ Description ^
| CARC Code | The standardized reason code from the payer explaining why the claim or line was adjusted. |
| Denial Count | How many service lines received this particular denial reason. |
| Total Amount | The total dollar impact of denials with this reason code. |
| Percentage | This reason code's share of all denials in the selected period. |

**Tips:**
  * The top 3-5 denial reasons typically account for the majority of lost revenue.
  * CARC codes like CO-4 (modifier issue) and CO-197 (prior auth) often point to correctable front-end problems.

==== Denial Write-Off ====

Tracks denied amounts that were written off versus recovered through appeals or resubmission.

**Key Metrics:**
^ Metric ^ Description ^
| Write-Off Rate | The percentage of denied dollars that were ultimately written off as uncollectable. |
| Recovery Rate | The percentage of denied dollars that were successfully recovered through appeals or corrections. |
| Denied Amount | The original dollar amount that was denied by the payer. |

**Tips:**
  * A high write-off rate may indicate that appeals are not being pursued consistently.
  * Track recovery rate trends monthly to measure the impact of process improvements.

==== Appeal Success ====

Measures the success rate of claim appeals by payer and over time.

**Key Metrics:**
^ Metric ^ Description ^
| Appeal Rate | The percentage of denied claims that were appealed rather than written off. |
| Win Rate | The percentage of appeals that resulted in payment (full or partial). |
| Recovered Amount | Total dollars recovered through successful appeals. |

**Tips:**
  * Payers with win rates above 50% are strong candidates for consistent appeal efforts.
  * If appeal rates are low but win rates are high, you may be leaving recoverable revenue on the table.

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===== Payer Intelligence =====

Reports for evaluating payer performance, detecting anomalies, and tracking acceptance rates.

==== Payer Summary ====

High-level overview of claim volume, payments, and adjustments for each payer. A good starting point for understanding your payer mix.

==== Payer Scorecard ====

Comprehensive performance comparison across all payers. Combines payment speed, collection yield, denial rates, and volume into a single comparative view.

**Key Metrics:**
^ Metric ^ Description ^
| Collection Yield | The percentage of billed charges actually collected from each payer. |
| Avg Days to Pay | Average turnaround time from submission to payment for each payer. |
| Denial Rate | The percentage of claims denied by each payer. |
| Claim Volume | Total number of claims processed for each payer. |

**Tips:**
  * Use this report for annual payer contract negotiations — data-driven conversations lead to better terms.
  * Sort by different columns to identify payers that are problematic in specific areas.

==== Payer Anomalies ====

Automatically detects unusual changes in payer behavior by comparing recent activity against historical baselines.

**Key Metrics:**
^ Metric ^ Description ^
| Deviation | How far the recent metric deviates from the historical baseline, expressed as a percentage. |
| Baseline | The average value from the prior 90-day period used for comparison. |
| Recent Value | The metric value from the most recent 30-day period. |

**Tips:**
  * Negative payment deviations may indicate a payer has changed their fee schedule or processing rules.
  * Sudden spikes in denial rates often correspond to payer policy changes or system updates.

==== Acceptance Rate ====

Tracks the percentage of claims accepted by each payer after submission.

**Key Metrics:**
^ Metric ^ Description ^
| Acceptance Rate | The percentage of submitted claims that were accepted for processing by the payer. |
| Total Submitted | Number of claims submitted to the payer. |
| Total Accepted | Number of claims accepted for adjudication. |
| Rejected / Pending | Claims that were rejected or are still awaiting a response. |

**Tips:**
  * Rates below 90% for any payer warrant investigation into common rejection reasons.
  * Compare against the Clean Claim Rate report to distinguish submission errors from payer-side rejections.

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===== Coding & Compliance =====

Reports for tracking procedure code changes, CARC trends, profitability, and contracted rates.

==== Procedure Code Changes ====

Identifies claims where the payer adjudicated a different procedure code than what was originally submitted. This may indicate downcoding, bundling, or legitimate code corrections.

**Key Metrics:**
^ Metric ^ Description ^
| Change Rate | The percentage of service lines where the payer changed the procedure code during adjudication. |
| Original Code | The procedure code submitted on the original claim. |
| Adjudicated Code | The procedure code the payer used for payment calculation. |

**Tips:**
  * Frequent downcoding (higher code changed to lower) by a specific payer may indicate aggressive payment policies.
  * Some code changes are legitimate corrections — focus on patterns rather than individual occurrences.

==== CARC Trends ====

Tracks Claim Adjustment Reason Code (CARC) volumes and dollar amounts over time. Shows whether specific adjustment reasons are increasing or decreasing.

**Key Metrics:**
^ Metric ^ Description ^
| CARC Code | The standardized code explaining why a claim payment was adjusted. |
| Frequency | How many times this adjustment reason appeared in the selected period. |
| Total Amount | The total dollar impact of adjustments with this reason code. |

**Tips:**
  * Watch for CARC codes that are trending upward month-over-month — they may indicate new payer rules or process breakdowns.
  * Cross-reference with the **Denial Root Cause** report for a complete picture of adjustment impacts.

==== Procedure Profitability ====

Analyzes the financial performance of each procedure code by comparing charges, payments, and costs.

**Key Metrics:**
^ Metric ^ Description ^
| Margin | The percentage of revenue retained after accounting for adjustments and denials. |
| Denial Rate | The percentage of service lines for this procedure code that were denied. |
| Avg Payment | The average payment received per service line for this procedure code. |

**Tips:**
  * Procedures with high volume but low margin may benefit from contract renegotiation.
  * High denial rates on specific procedures often point to documentation or coding education opportunities.

==== Contracted Rates ====

Manages the expected payment rates for each payer and procedure code. These contracted rates are used by other SharpInsight reports (like Underpayment Detection) to calculate payment variances.

**Key Metrics:**
^ Metric ^ Description ^
| Medicare Multiplier | The payer's contracted rate expressed as a multiplier of the Medicare fee schedule (e.g., 1.15 = 115% of Medicare). |
| Effective Date | When the contracted rate goes into effect. |
| Procedure Code | The specific CPT/HCPCS code this rate applies to. |

**Tips:**
  * Keep contracted rates up to date to ensure accurate underpayment detection.
  * If a payer uses a Medicare multiplier, you only need one entry rather than individual procedure rates.

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===== Claims Analysis =====

Reports for analyzing claim touch points, status code outcomes, and similar claims.

==== Claim Touch Analysis ====

Tracks how many times a claim is touched (submitted, corrected, resubmitted, appealed) before final resolution. Higher touch counts indicate process inefficiency.

**Key Metrics:**
^ Metric ^ Description ^
| First Pass Rate | The percentage of claims resolved with a single submission — no corrections or resubmissions needed. |
| Touch Count | The total number of submissions and resubmissions for a claim before final resolution. |
| 3+ Touches | The percentage of claims requiring three or more submission attempts. |

**Tips:**
  * Industry benchmark for first-pass resolution is 90%+. Below 80% suggests significant rework issues.
  * Claims with 3+ touches should be reviewed to identify common root causes of rework.

==== Status Code Outcomes ====

Shows the final financial outcomes grouped by claim status codes.

**Key Metrics:**
^ Metric ^ Description ^
| Status Code | The claim processing status code indicating how the claim was adjudicated. |
| Payment Rate | The percentage of claims with this status that resulted in payment. |
| Claim Count | The number of claims processed with this status code. |

**Tips:**
  * Status codes with low payment rates may indicate specific payer processing issues.
  * Use alongside **Denial Root Cause** for a complete view of claim adjudication outcomes.

==== Claim Similarity ====

Uses AI to find claims similar to a selected claim based on diagnosis codes, procedure codes, payer, and other attributes. Useful for researching how similar claims were adjudicated.

**Key Metrics:**
^ Metric ^ Description ^
| Similarity Score | A percentage indicating how closely a claim matches the reference claim. Higher scores mean more similar attributes. |
| Outcome | How the similar claim was ultimately resolved (Paid, Denied, Partial). |
| Payment Amount | What the similar claim was paid, useful for estimating expected payment on the reference claim. |

**Tips:**
  * Use this to research appeal strategy — find similar claims that were successfully paid after initial denial.
  * High similarity scores (90%+) provide the most reliable comparison data.

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===== MIPS Quality =====

<WRAP center round info 90%>
Don't see this section? Contact ClaimRev to have MIPS quality reporting enabled for your account.
</WRAP>

Reports for MIPS quality measure performance, gap analysis, and provider scorecards.

==== Performance Dashboard ====

Shows estimated MIPS composite quality score, per-measure performance rates, and projected Medicare Part B payment adjustment.

**Key Metrics:**
^ Metric ^ Description ^
| Composite Score | Weighted average of all active measure scores, on a 0-100 scale. CMS uses this to calculate payment adjustments. |
| Capture Rate | Percentage of eligible encounters where the required quality code was present. |
| Projected Adjustment | Estimated Medicare Part B payment adjustment based on current performance. Ranges from -9% to +9%. |

**Tips:**
  * Focus on high-priority measures first — they carry more weight in the composite score.
  * Export the quality summary CSV for submission preparation or internal review.

==== Gap Analysis ====

Breaks down quality code gaps by measure and by provider to identify where gaps are concentrated.

**Key Metrics:**
^ Metric ^ Description ^
| Pending Gaps | Gap alerts that have not yet been reviewed by a provider. |
| Confirmed | Gaps where the provider confirmed the quality code should be added. |
| Dismissed | Gaps dismissed as not applicable to the encounter. |

**Tips:**
  * High pending counts for a single measure may indicate a systematic documentation issue.
  * Use the **Gap Review Queue** to work through pending alerts.

==== Provider Scorecard ====

Compares quality performance across individual providers (NPIs).

**Key Metrics:**
^ Metric ^ Description ^
| Capture Rate | The provider's percentage of eligible encounters with quality codes present. |
| Estimated Points | Quality points earned based on performance rates across active measures. |
| Projected Adjustment | The provider's estimated Medicare payment adjustment based on their individual performance. |

**Tips:**
  * Providers with low capture rates may benefit from quality code documentation education.
  * Sort by capture rate to quickly identify providers who need the most improvement.

==== Capture Rate ====

Tracks quality code capture rate over time with monthly trends.

**Key Metrics:**
^ Metric ^ Description ^
| Current Rate | The capture rate for the selected performance year to date. |
| Prior Rate | The capture rate for the same period in the prior year, for comparison. |
| Change | The percentage point change between current and prior period rates. |

**Tips:**
  * A declining trend may indicate new measures were added without proper provider training.
  * Monthly detail helps identify seasonal patterns in quality code capture.

==== Gap Review Queue ====

Lists all pending quality code gap alerts awaiting provider review. Use this queue to systematically work through gaps.

**Key Metrics:**
^ Metric ^ Description ^
| Total Pending | The number of gap alerts that have not yet been reviewed. |
| Expected Codes | The quality codes that CMS expects for the triggered measure. |

**Tips:**
  * Work through the queue regularly to ensure gaps are addressed before the end of the performance year.
  * Click on a row to navigate to the claim detail MIPS tab for confirm/dismiss actions.

==== Measure Config ====

Manages which MIPS quality measures are active for your account.

**Key Metrics:**
^ Metric ^ Description ^
| Active Measures | Measures currently enabled for gap detection during claim validation. |
| Import History | Audit trail of CMS measure data imports showing counts and status. |

**Tips:**
  * Import CMS measures at the start of each performance year to get updated measure definitions.
  * Toggle measures off if they are not relevant to your practice specialty.

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===== Settings =====

Click the **gear icon** in the sidebar header to access SharpInsight configuration settings. Settings include:

  * **Variance thresholds** — Configure the dollar amount and percentage thresholds used by the Underpayment Detection report
  * **Similarity settings** — Set the minimum similarity score and maximum results for the Claim Similarity report
  * **CARC exclusions** — Exclude specific CARC codes from trending and analysis
  * **Denial settings** — Configure write-off threshold days and appeal detection behavior

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