How to Choose the Right Medical Claims Clearinghouse for Your Office

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You’ve made the decision that using a medical claims clearinghouse is the right avenue to take. Now you have the decision of choosing the right clearinghouse. Where do you start and how do you decide what is the best value for your practice? Here’s how to choose the best option for your facility.

Understand How a Medical Clearinghouse Works

When healthcare facilities install medical billing software, each claim becomes a file known as an ANSI-X12- 837. Software uploads the file to your medical claims clearinghouse where it is checked for errors, then transmitted electronically to the payer. Each transmission takes place over the secure connections required by the Health Insurance Portability and Accountability Act (HIPAA).

The payer will either accept or reject the claim. Once they make their decision, your clearinghouse receives a status update and adds them to the control panel on your machine. Your claims department can make changes from there and resubmit them for payment.

If the claim doesn’t require any corrections, the payer will send you money through an electronic funds transfer (EFT) and an explanation of benefits.

The process is similar to what happens in banking, with financial institutions sending secure transactions electronically, checking them for errors at each step along the way. If there’s a breakdown at any point, the transaction can be tracked so no information is lost and errors can be quickly corrected. Here are a few of the benefits of using a medical claims clearinghouse:

  • Healthcare providers can review and fix errors in minutes instead of waiting days before even finding out there’s a problem.
  • Clearinghouses drastically reduce error rates. Paper claims have errors that result in denial an estimated 28 percent of the time. The right clearinghouse can cut that number to between two and three percent.
  • Clearinghouses save manpower. Send claims in a batch instead of submitting them one at a time and spend less time correcting medical billing mistakes.
  • Your organization has access to more accurate data. Manage electronic claims from a single location and make more precise revenue forecasts with reduced payment cycles.

Evaluate Your Options

There are a wide variety of medical claims clearinghouses, and they don’t all provide the same value and services. Gather data on the ones you’re considering by asking the following questions of each:

  • Does the clearinghouse service organizations nationwide?
  • Are the insurances you bill on their payer list?
  • Do they offer online access for tracking and updating submitted claims?
  • What type of support do they provide once claims are submitted?
  • What type of contract do they require and what happens if you later choose to switch to another provider?
  • Do they charge on a monthly basis or per submission?
  • Do they offer analysis for rejected claims?
  • If insurance providers require paper-based claims, will the clearinghouse mail them for you?
  • How does the clearinghouse update your facility when payers process claims or send financial transactions?

Prioritize Customer Support

In order to select the best option for your facility and your patients, choose a medical claims clearinghouse that offers responsive customer service. For your facility, if your staff has to wait for hours on the phone to speak to a representative or wait days for a question to be answered, it costs you money.

Select a clearinghouse that lets you request support around the clock and will respond within 24 hours. Most clearinghouses include their customer service commitment in their contract. Qualified clearinghouses have a technical support line and are responsive when you have questions.

Ask About Claim Responses

One of the benefits of using a medical claims clearinghouse is receiving quick updates once you submit claims. Once you upload claims, scrubbing them for errors and submitting them to payers takes minutes. You should know the same day if claims were accepted or if they need to be corrected and resubmitted.

Select a clearinghouse that offers claim status for individual claims. Reduce delays to improve your relationship with clients and get paid faster.

Verify Accuracy with 835s

HIPAA requires healthcare insurance plans to use the 835 transaction set when paying providers and to provide an explanation of benefits (EOB). Some medical claims clearinghouses take weeks or months after the transaction is complete to send 835s to healthcare facilities.

When there’s a delay, your staff spends time waiting on them. Choose a provider that sends both 835s and payments within a dependable timeframe so you can post payments and reconcile information. The best services do not charge extra for ERA 835 transactions.

If you handle a high volume of billing, electronic remittance files can save you time. An electronic remittance is a digital version of an EOB. Download the file and post it to your clearinghouse software to avoid having to manually post payments from individual EOBs.

Evaluate Usability

Find software that meets the needs of your practice and is easy to access by all the necessary staff members. Not only do you need all the claim information accessible n your system, it’s often necessary for it to be accessible to multiple staff members at once. Give your staff the capability to update claims as they post payment or resubmit corrections so you can view all activity without having to pull up individual claims.

Verify compatibility with your current claims billing software and evaluate whether the error reports and control panel provide simple navigation. Check to see if claim errors are written in language that is easy for staff to decipher.

Select a clearinghouse that lets you verify patient eligibility in real-time and offers extensive searching functionality for data access. Advanced revenue cycle features also offer features like rejection analysis, secondary claims processing, patient statements and free summaries of your activity with the clearinghouse.

Apex EDI has been processing claims for doctors, dentists, optometrists, chiropractors and other practices since 1995. Our software integrates with almost any billing software and we support more healthcare payers than any other clearinghouse. Contact us to find out how we can get you paid faster so you can focus on serving your patients.




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