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: De-identified medical claims highlighting referrals with an explicitly named referring provider on the claim that counts if the referral resulted in a completed visit. Self-referrals, verbal recommendations, patient self-referrals, and referrals that do not resolve in an encounter are excluded.

Referral Sorting: Referrals where you are listed as the referring provider and receiving provider are determined.

Peer Benchmarking: Peers are providers in your specialty and area (CBSA or county if enough peers, otherwise state).

Opportunities Determined: If you have enough claims data to determine the diagnosis you treat, peers identified in the peer benchmarking step are checked to show referrals for diagnoses you have treated. For example, if you have two or more claims with a primary diagnosis in the previous 12 finished months.

Outputs:

  • Opportunities: Top line items include Referral Volume in Your Market, determined by referrals received by clinicians in your specialty for a diagnosis you treat who work in your local area. Referral Revenue in Your Market is based on payments for the referred visits, or billed amounts when payment data is unavailable. Average Revenue per Referral is highlighted as the last top line item. In the table, top referrers are ranked by the total revenue from the new patient encounter resulting from the referral. This amount can vary for each referral, as they might be covered by different payers and the complexity of the encounter might differ.
  • Received: Your new patient encounters that have 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 below shows the top providers referring to you.
  • Sent: New patients you referred to other providers in 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 provider who received the referral 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: Medical claims data from the previous 12 finished months. Institutional and facility claims, claims where you are not the rendering provider, bundled or modified claims (Negotiated only), and claims with insufficient data are excluded from calculations.

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

Peer Benchmarking & Medians: 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 eliminate any existing outliers.

Output:

  • Reimbursed: How your reimbursement per procedure over the last 12 finished months compares to 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 alongside the associated code, description and payer, and total claims.
  • Negotiated: How your contracted (negotiated) rates per procedure compare to peers, by payer. Revenue opportunity shows how much more your claims would have generated had your negotiated rate matched the peer median. Similarly to reimbursed, the table displays top 10 activities by total revenue opportunity alongside the associated code, description and payer, and total claims.

How Denials Are Surfaced

Data Sources: 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 (write-downs already built into your payer contracts) are not included as denials.

CARC Codes Applied: Claim Adjustment Reason Codes that cause your claims to be denied. These 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 a 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 amounts for you and your peers denied claims by payers. Medians are used to avoid outliers skewing data.

Billed Amounts Applied: Dollar amounts reflect billed charges, not what your contracted rate with each payer would actually pay out. 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 that has the highest denial rate (percentage of claims that were denied). A table below provides 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 in the Referrals tab. You can provide feedback from the Opportunities, Received, or Sent tabs by drilling into a provider in the table of a tab. The thumbs up and thumbs down icons are located in the top right of the provider card. Choosing either icon will open a "Tell us more" window, where you can optionally select a category and describe your feedback in the text box. While categories and descriptions are not required, they are useful to inform Jiro where Referrals are performing as planned or where they can be improved.

Feedback does not immediately affect 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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