How Financial Performance Works

Overview

This article describes how to navigate the Financial tab of the Performance section of Practice and explains how underlying Referral, Reimbursement, Denial, and Encounter Coding data is sourced, defined, and timed.

Navigating Financial Performance

You land on the Referrals tab by default. If you have no referral data, Reimbursements becomes your landing tab. The same logic applies if your reimbursement data is empty, in which case Denials becomes the default tab, followed by Encounter Coding if you have no denials.

How Referrals Are Surfaced

Data Sources: Your referral data comes from de-identified medical claims that name a referring provider. A referral counts only if it results in a completed visit. Self-referrals, verbal recommendations, patient self-referrals, and referrals that do not lead to an encounter are excluded.

Referral Sorting: Jiro identifies referrals where you are listed as either the referring provider or the receiving provider.

Peer Benchmarking: Your peers are providers in your specialty and area, using CBSA or county-level data when there are enough peers, otherwise state-level data.

Opportunities Determined: If you have enough claims data to determine the diagnoses you treat, Jiro checks your peers to surface referrals for diagnoses you have treated. For example, if you have two or more claims with a given primary diagnosis in the previous 12 finished months.

Outputs:

  • Opportunities: Top-line items include Referral Volume in Your Market, based on referrals received by clinicians in your specialty and area for diagnoses you treat. Referral Revenue in Your Market reflects payments for the referred visits, or billed amounts when payment data is unavailable. Average Revenue per Referral is the final top-line item. The table ranks top referrers by the total revenue from the new patient encounter resulting from each referral. This revenue can vary by referral, since payers and encounter complexity differ.
  • Received: Your new patient encounters with a known referrer over the last 12 finished months. Revenue reflects the paid amount for the new patient visit, including all activities on the day of the visit, or the billed amount when payment data is unavailable. The table shows the top providers referring to you.
  • Sent: New patients you referred to other providers over the past 12 months. These referrals appear when the receiving provider records you as the referrer on the patient’s new encounter. Revenue reflects the paid amount to the receiving provider for the new patient visit, including all activities on the day of the visit, or the billed amount when payment data is unavailable. The table shows where you refer your patients most often.

How Reimbursements Are Surfaced

Data Sources: Your reimbursement data draws from medical claims over the previous 12 finished months. Institutional and facility claims, claims where you are not the rendering provider, bundled or modified claims (Negotiated tab only), and claims with insufficient data are excluded.

The Reimbursed tab uses allowed amounts from your professional claims, excluding denied lines. The Negotiated tab uses published contract rates from payer transparency sources when available, broken down by payer.

Peer Benchmarking & Medians: Your peer group is determined by specialty and geography. Jiro compares the median reimbursed or negotiated rate of your activity to the corresponding median of your peers. Medians are used to reduce the effect of outliers.

Outputs:

  • Reimbursed: Shows how your reimbursement per procedure over the last 12 finished months compares to your peers, by payer. Revenue opportunity shows how much more those claims would have generated had they matched the peer median. The table highlights your top 10 activities by total revenue opportunity, along with the associated code, description, payer, and total claims.
  • Negotiated: Shows how your contracted rates per procedure compare to your peers, by payer. Revenue opportunity shows how much more your claims would have generated had your negotiated rate matched the peer median. As with the Reimbursed tab, the table displays your top 10 activities by total revenue opportunity, along with the associated code, description, payer, and total claims.

How Denials Are Surfaced

Data Sources: Your denial data includes fully denied claims over the previous 12 finished months. Claims that were paid but had an individual service line denied are excluded, as are claims that are pending or under appeal. Contractual adjustments, the write-downs already built into your payer contracts, are also not counted as denials.

CARC Codes Applied: Claim Adjustment Reason Codes (CARC) that cause your claims to be denied are grouped into the most common categories by volume. Less frequent reasons are rolled into a single "Other" category.

Peer Benchmarking: Your mean complexity and mean RVUs are compared against the mean of providers in your selected specialty and geography.

Medians Are Calculated: Your denial rate is calculated as denied claims divided by claims with a known payer decision. Median denied claim amounts are calculated for you and your peers by payer. Medians are used to avoid outliers skewing the data.

Billed Amounts Applied: Dollar amounts reflect billed charges, not what your contracted rate with each payer would actually pay. Your real recoverable amount is typically lower.

Output: Your claims denial loss is presented as the reflected amount of billed charges, alongside Total Claims Denied and Highest Denial Rate as top-line items. Highest Denial Rate is the combination of category and payer with the highest denial rate, the percentage of claims that were denied. A table below shows your Denial Breakdown organized by Total Denied Claims Value.

How Encounter Coding Is Surfaced

Data Sources: Your office and outpatient professional claims from the last 12 finished months are used. Institutional and facility claims are not included.

Complexity: Your claims are measured on a scale of 1 to 4, from straightforward to high, based on the Medical Decision Making level associated with each CPT code.

Work RVUs: Your claims are sorted into work RVUs, referenced from the CMS federal fee schedule.

Peer Benchmarking: Your mean complexity and mean RVUs are compared against the mean of providers in your specialty and geography.

Output: Your established and new encounters are displayed on the scale at the top of the tab relative to your peers. Each drop-down option for Established and New patient encounters shows Encounters Analyzed, RVUs Above Peers, and Complexity vs. Peers, with a breakdown by complexity in the table at the bottom of the tab.

Giving Feedback On Financial Performance Features

Currently, feedback is supported only in the Referrals tab. You can provide feedback from the Opportunities, Received, or Sent tabs by clicking into a provider in the table. The thumbs up and thumbs down icons are located in the top right of the provider card. Choosing either icon opens a "Tell us more" window, where you can optionally select a category and describe your feedback in the text box. Categories and descriptions are not required, but they help Jiro understand where Referrals are performing well or where they can be improved.

Submitting feedback does not immediately change your Financial Performance section of Practice.

Important To Remember

  • All financial metrics are derived from medical claims over the previous 12 finished months
  • Only referrals resulting in a documented encounter are included. Self-referrals, verbal recommendations, and referrals that do not lead to a visit are excluded.
  • Revenue figures reflect paid amounts or billed charges when payment data is unavailable. Billed amounts for denials do not reflect actual recoverable revenue, which is typically lower.
  • Institutional and facility claims, bundled or modified professional claims, and claims where you are not the rendering provider are excluded from reimbursement and encounter coding metrics.
  • Only fully denied claims are surfaced. Claims with individual line denials, pending status, or those under appeal are not included.
  • Benchmarking is performed at the CBSA or county level when sample sizes are sufficient; otherwise, state-level data is used to ensure statistical reliability.
  • Submitting feedback on referral data helps improve future accuracy but will not result in an instantaneous change to your current Practice view.

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