Health Industry

Health Insurance KPIs: Top 21 Core Metrics to Track

November 4, 2023

The health insurance market is in a constant state of flux, fraught with new difficulties and promising prospects. Health insurance companies must use key performance indicators (KPIs) for data-driven decision-making and superior operations to succeed in a highly competitive market. By concentrating on the proper health insurance KPIs, insurers may optimize processes, enhance customer experiences, and generate sustainable growth. 

In this comprehensive guide, we delve into the top 21 core KPIs that are imperative for tracking and understanding the pulse of the health insurance sector.

The Crucial Role of KPIs in Health Insurance

An in-depth familiarity with health insurance performance metrics is essential for effective management. Key performance indicators are the map that helps healthcare providers and payers provide the best treatment possible to their clients. Whether a seasoned executive or a data-driven worker, your firm will benefit from focusing on these 21 health insurance KPIs.

Financial Performance KPIs

Claims Ratio

The industry average claims ratio is approximately 70%, indicating that, on average, 70% of premiums earned are used to cover claims.

The claims ratio is a key indicator of a health insurance company’s financial stability. Insurers can maintain a healthy premium-to-claims ratio by monitoring this key performance indicator.

Formula: (Total Claims Incurred / Total Premiums Earned) * 100

Loss Ratio

The typical loss ratio for health insurance providers is around 80%, reflecting that 80% of premiums earned go toward covering claims.

The loss ratio is a key metric since it reveals how much losses exceed premiums collected. Insurers can evaluate the efficiency of their underwriting and claims handling by looking at the loss ratio and then make any required improvements to ensure continued profitability.

Formula: (Total Claims Paid / Total Premiums Earned) * 100

Premium Growth Rate

Health insurance premium growth rates have averaged around 6-7% annually. A health insurance company’s future success can be gauged by keeping a close eye on its premium growth rate. These health insurance KPIs can help insurers evaluate the success of their sales and marketing efforts, opening doors to long-term premium increases and broader market penetration.

Formula: ((Current Year’s Premiums – Last Year’s Premiums) / Last Year’s Premiums) * 100

Cost per Claim

The rising cost of health insurance in 2023 is becoming clearer, and it’s not nice. Fully insured enterprises that buy health insurance for their employees will pay 6.5% more per employee than last year.

Keeping an eye on operational costs and ensuring efficient claims processing requires regular reviews of the cost per claim. Insurers may save money, improve their claims-handling procedures, and make the most of their resources by monitoring this key performance indicator.

Formula: (Total Claims Processing Costs / Total Number of Claims Processed)

Solvency Ratio

According to Irdai guidelines, all companies are required to maintain a solvency ratio of 150% to minimize bankruptcy risk.

The solvency ratio is an important indicator of an insurer’s long-term and solvency risks. Insurers can retain financial strength, gain policyholder and stakeholder confidence, and follow all applicable regulations by measuring their solvency ratio.

Formula: (Total Assets / Total Liabilities)

Medical Loss Ratio (MLR)

Large group insurers have a stricter MLR standard since they must devote at least 85% of revenue to covering medical expenses and enhancing care quality.

As a critical performance metric, the medical loss ratio tracks how much of a company’s budget goes toward paying for medical claims and other medical care. Insurers can optimize cost structures and sustain profitability by studying the MLR to evaluate their medical cost management techniques.

Formula: (Total Medical Costs Incurred / Total Premiums Earned) * 100

Claims Denial Rate

Statistics show that almost 60% of denied claims are never resubmitted and that roughly 20% of all claims are declined.

Keeping an eye on the percentage of rejected claims is crucial for boosting claims management efficiency. These health insurance KPIs help insurers identify claim denial causes, take corrective action, and improve the claims resolution process for prompt and accurate claim settlements.

Formula: (Number of Claims Denied / Total Number of Claims Submitted) * 100

Customer Satisfaction and Retention KPIs

Customer Retention Rate

The financial services industry typically retains 78% of its customers. The health insurance business has a retention rate of 75%, slightly lower than the overall average.

Regarding long-term customer relationships, health insurance companies place a premium on customer retention. Insurers can gauge the success of their efforts to maintain customers’ loyalty and confidence by monitoring their retention rate.

Formula: ((Number of Customers at the End of the Period – Number of Customers Acquired During the Period) / Number of Customers at the Start of the Period) * 100

Net Promoter Score (NPS)

The NPS in the health insurance industry typically ranges from -100 to 100, with top-performing companies achieving scores above 50.

If you want to know how satisfied and loyal your customers are, go beyond the Net Promoter Score. Insurers can improve service and client retention by knowing the NPS and customer views and experiences.

Formula: NPS = (% Promoters – % Detractors)

Policy Renewal Rate

The rate at which policies are renewed speaks volumes about the satisfaction and loyalty of policyholders. By tracking these health insurance KPIs, insurers can identify variables impacting policy renewals, enabling them to modify their goods and services to match consumer expectations and retain customers. A strong policy renewal rate often surpasses 85%, demonstrating policyholder satisfaction.

Formula: (Number of Policies Renewed / Total Number of Policies Eligible for Renewal) * 100

Operational Efficiency KPIs

Underwriting Time

The time it takes to underwrite an insurance policy is a critical key performance indicator. By reducing delays in policy issuance and improving client satisfaction, prompt underwriting speeds up the entire insurance process. On average, it takes 15 to 30 days for underwriters to process a health insurance policy application.

Formula: (Total Time Taken for Underwriting / Number of Policies Underwritten)

Average Claims Processing Time

The average time it takes to process a claim is a critical indicator of how well the claims system is functioning. Insurers can improve customer happiness, operational efficiency, and reputation for rapid and reliable service by reducing claims processing time. On average, it takes 30 to 45 days to process health insurance claims.

Formula: (Total Time Spent on Claims Processing / Total Number of Claims Processed)

Average Time to Issue Policies

One of the most important indicators of policy issuance efficiency is the median time to issue a policy. These health insurance KPIs can help insurers improve policy issuance operations, customer experiences, and policyholder delivery, improving operational agility and responsiveness. Health insurance coverage typically takes between 20 and 30 days to be issued.

Formula: (Total Time Taken to Issue Policies / Number of Policies Issued)

Complaint Resolution Time

Maintaining customer satisfaction and confidence requires prompt and effective resolution of policyholder complaints. Tracking complaint resolution time helps insurers improve dispute resolution, streamline complaint management, and demonstrate their commitment to customer service. Effective complaint resolution typically takes an average of 15 to 30 days.

Formula: (Total Time Taken to Resolve Complaints / Number of Complaints Resolved)

Health and Wellness KPIs

Health Risk Assessment Accuracy

The dependability of underwriting choices and risk management techniques relies heavily on the precision of health risk assessments. To reduce adverse selection and financial risks, insurers use health risk assessments to improve underwriting and pricing. Accuracy rates for health risk assessments typically range from 80% to 90%.

Formula: (Number of Correctly Assessed Health Risks / Total Number of Health Risk Assessments Conducted) * 100

Health Management Program Participation Rate

Health management program participation rates are a key indicator of the success of wellness programs. These health KPIs help insurers evaluate health management programs’ effects on policyholders’ health, promoting preventative care and healthy lives. High participation rates in health management programs can reach 60% or more.

Formula: (Number of Participants in Health Management Programs / Total Number of Eligible Participants) * 100

Disease Management Program Effectiveness

The effectiveness of disease management programs can be measured by improvements in health outcomes, with success rates ranging from 60% to 80%.

Promoting beneficial health outcomes and decreasing healthcare expenditures necessitates evaluating the efficiency of disease management programs. These medical insurance KPIs can help insurers assess how illness management activities affect policyholders’ well-being, supporting proactive healthcare management and quality of life. 

Formula: (Number of Participants with Improved Health Outcomes / Total Number of Participants in Disease Management Programs) * 100

Member Health Improvement Rate

Evaluation of wellness and health promotion programs requires tracking member health progress. These healthcare insurance KPIs can help insurers track policyholder health changes, justify health improvement activities, and promote preventative care and well-being.

Preventive Care Compliance

Policyholders’ compliance rate with prescribed preventive healthcare interventions is an important indicator of overall health and financial stability. Insurers can reward preventative care compliance, reduce healthcare costs, and promote healthier lifestyles by monitoring these health insurance KPIs. High compliance rates for preventive care measures can reach 75% or more among policyholders.

Formula: (Number of Policyholders Compliant with Preventive Care Measures / Total Number of Policyholders) * 100

Network and Provider Management KPIs

Provider Network Adequacy

The adequacy of a provider network is an important indicator of a health insurance plan’s ability to meet its members’ healthcare needs. Insurers can use this KPI to provide better health insurance to their policyholders. Adequate provider networks generally encompass 85% or more healthcare providers in a given area.

Formula: (Number of Providers in Network / Total Number of Providers Available) * 100

Utilization Rate

A policyholder’s utilization rate is a crucial indicator of how often and how many healthcare services they really use. Insurers can improve healthcare delivery efficiency and lower costs by tracking this key performance indicator and responding to emerging trends in patient needs. The utilization rate is an average of 5 to 10 healthcare services per insured person annually.

Formula: (Total Healthcare Service Utilization / Total Number of Insured Persons)

Challenges and Considerations

The above health insurance KPIs provide a thorough framework for tracking and improving health insurance performance, but they also present obstacles and considerations:

Data Quality and Integration

The integration and gathering of data must be reliable and consistent if health insurance KPIs are to be tracked effectively. In order to guarantee the quality and consistency of their data, health insurance companies need to invest in advanced data management and analytics tools.

Regulatory Compliance

There are a plethora of rules and regulations that the health insurance sector must follow. Avoiding legal trouble requires keeping up with regulations and making sure they are followed.

Member Privacy

It is crucial that policyholders’ personal information and privacy be safeguarded. For member confidence and legal compliance, health insurers need to establish rigorous data protection procedures.

Technological Advancements

Embracing digital transformation and emerging technologies is a strategic priority. To maintain a competitive edge, insurers should look at cutting-edge data analytics, AI, and telemedicine technologies.

Customer Engagement

It might be difficult to get policyholders interested in wellness programs and preventative treatment. To encourage healthier actions and better health outcomes, insurance companies must develop efficient engagement tactics.

The Real-World Impact of Health Insurance KPIs

In practice, there are many advantages for health insurance companies when they monitor these health insurance KPIs:

  • Financial Stability: Insurers can maintain financial stability and make sound decisions when they have a firm grasp on claims ratios, loss ratios, and solvency ratios.
  • Customer Satisfaction: Customer happiness is influenced by KPIs such as Net Promoter Score and Customer Retention Rate. Customers happy with their coverage are more inclined to renew and refer the insurer to others.
  • Operational Efficiency: Operational efficiency and cost-effectiveness are aided by metrics such as underwriting time, claims processing time, and policy issuing time.
  • Quality Healthcare Delivery: Policyholders receive high-quality treatment when provider networks are sufficient, utilization rates are low, and disease management programs are efficient.
  • Risk Management: Insurers are able to mitigate the effects of adverse selection through better risk management thanks to improvements in health risk assessment accuracy and illness management effectiveness.

How Can Brickclay Help?

Health insurance firms can benefit from Brickclay’s expertise as a leading provider of data analytics and data management solutions. Insurers can benefit from our data integration engineering services, data analytics solutions, health insurance KPI dashboards, and healthcare-specific expertise by achieving the following:

  • Optimize Data Management: By streamlining data administration, Brickclay helps insurers in keeping track of and analyzing key performance indicators.
  • Data Analytics: Our data analytics services deliver insights that can be put into practice, helping to guide decision-making and enhance the delivery of healthcare.
  • Data Privacy and Security: To ensure the safety of our policyholders’ personal information, we place a premium on data privacy and security.
  • Predictive Modeling: To enable proactive management of claims, risks, and member behavior, Brickclay uses predictive modeling.
  • Telehealth Integration: We facilitate the integration of telehealth services, aligning with the expanding trend of remote healthcare access.

This detailed guide covers health insurance KPIs, problems, real-world implications, and how Brickclay may help health insurers. The health insurance industry’s upper management, chief human resources officers, managing directors, and country managers will find it useful.

If you’re ready to elevate your health insurance operations through data-driven strategies, don’t hesitate to contact us today.

About Brickclay

Brickclay is a digital solutions provider that empowers businesses with data-driven strategies and innovative solutions. Our team of experts specializes in digital marketing, web design and development, big data and BI. We work with businesses of all sizes and industries to deliver customized, comprehensive solutions that help them achieve their goals.

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