In today’s fast-paced and instantaneous digital world, every healthcare provider needs to use a clearinghouse to help process their medical claims—but each one offers different features, packages and price points. To get the most out of your clearinghouse solution and yield the best results for your revenue cycle, healthcare providers need to consider their options.

What Is a Clearinghouse?

A clearinghouse acts as the “middle man” between a healthcare provider’s billing department and the insurance payer. To submit a claim, providers import a file from their medical billing software into a clearinghouse, which then performs a data verification or “scrub” before releasing it on to the insurance payer. The payer then reviews the claim and accepts or rejects the submission. After further review and adjudication, the claim will be approved for payment or returned as a denial.

Without a clearinghouse, healthcare providers would be required to submit claims through payer portals, which would require access to multiple systems, or on paper by mail.

Is It Time to Switch or Upgrade Your Clearinghouse Solution?

When budgets are already tight, it’s understandable why some providers prefer to get by with the bare minimum when it comes to their clearinghouse solutions. Their goal is to simply get clean claims out the door. What they may not realize, however, is that certain add-ons could allow for significant savings in the long run. For example, by upgrading your solution to include denials management, your internal staff can reduce time spent on reviewing, correcting, and appealing claims. Tools provided in the denial management module streamline processes for denial resolution.

To determine whether your organization might benefit from a change, ask yourself the following:

• Are you using multiple clearinghouse solutions?
• Are you experiencing a high number of rejections or denials?
• Does your current solution offer basic claim editing, payer edits, and notifications?
• Can you bill all the payers you need to?
• Do you need more robust reporting?
  
  

Standard Clearinghouse Requirements

While there are many unique features each clearinghouse offers, some of what we consider standard – and necessary – and should be included regardless of the package you select. At a minimum, ensure your solution provides the following:

• Eligibility verification: Determine the patient’s payment responsibility even before their appointment
• Electronic Remittance Advice (ERA): Automatically updates payments and adjustments
• Claim status reports: Always know the status of a claim
• Rejection analysis: Get error codes explained in plain English
• Printed claims: Have claims automatically dropped to paper when necessary, but retain the ability to track and manage them online
• Online access: Edit and correct claims day or night, online at your convenience
  
  

Clearinghouse System Enhancements

In many cases, it may make sense to explore more advanced solutions beyond basic claims processing. By layering one or more of these optional offerings, providers can gain greater efficiency by centralizing data, reducing errors and denials, and shortening payment cycles.

• Additional scrubs: An additional data review is performed before submitting to the payer, to help minimize denial and rejection rates
• Denial management: Any denied claims are identified and reworked by the clearinghouse until the issue is resolved, creating a more streamlined process
• Reporting: Easily retrieve information such as the number of claims submitted and denied within a specified time frame, so you can monitor performance and make necessary adjustments
• Customization: Make the system work for your organization by setting up specific payer rules
  
  

Other Clearinghouse Considerations

Before making any drastic changes to your clearinghouse, there are a few things to keep in mind. As one would anticipate when pulling the plug on any kind of database, there can be a loss of your claim history. That is, unless you request a data file that can be used for future reference or audits, or you can continue paying your old vendor for access to that historical information. Many providers choose to pay for a few months until they are more settled into the new system, but it can be costly to maintain ongoing access. (Note that your data will still be available in your EHR history, but it will be much more cumbersome and inefficient to retrieve.)

Since cost is always such a huge factor, beware of any hidden costs before jumping into a new contract. Understand the terms being proposed and how it could affect your monthly bill. Will you be operating on a tier for the number of claims you can submit each month, or is it unlimited? If you need to correct a claim, can it be resubmitted without a cost? This is the insight you will want to have upfront so you can budget accordingly.

As you begin shopping around for a new clearinghouse, be sure to seek input from industry peers. Some systems are catered more towards home health or post-acute care providers, for example, so inquire whether other similar users are happy with their choice. Take advantage of offers to see system demos, and pay particular attention to features such as ease of navigation and intuitive control panels.

Contact Richter’s Revenue Cycle and Reimbursement Team

The bottom line is you want to achieve faster turnaround on claim processing, which leads to increased cash flow for your organization. If your clearinghouse isn’t delivering just that—it may be time for a change. For help discussing your options, reach out to Richter’s Revenue Cycle and Reimbursement Consulting team. You can also contact us here or call us at 866.806.0799.