Claims Clearinghouse - Did You Know You Have a Choice?

It seems like just yesterday, as the CEO of a multi-provider ophthalmology center and ambulatory surgery center, I was faced with the challenges of finding a new practice management system and implementing electronic medical records into our organization's processes. Though there were many decisions and choices to be made, the one decision I didn’t make was the claims clearinghouse we would use. At the time, no one told me I had a choice and, as a result, we encountered many revenue cycle management issues and our productivity suffered greatly.

You’re paying for your claims clearinghouse, but are you getting any benefits?

How much is your claims clearing costing you? Odds are you are either paying the clearinghouse directly or paying for it through your practice management support vendor. Either way, you should be asking yourself if you’re getting what your organization needs. A good claims clearinghouse product should offer many benefits that assist in streamlining processes in your front office operations and should provide value added services that improve your revenue cycle management. 

What benefits should a good claims clearinghouse provide?

There’s more to filing claims electronically than just the press of a send button. How many times have you struggled with report inaccuracy from your practice management system or had the front office and your billing operations at odds because data was input incorrectly or insurance verifications were incomplete? How many times have your billers received a payer reply stating “No claim on file” when you know it’s been submitted? These issues should all be resolved and handled by a properly functioning claims clearinghouse. You should be asking yourself if your claims clearinghouse offers:

  • Interface Ability - Your clearinghouse should interface with your practice management software to ensure that all features are fully functional. 

  • Comprehensive SupportSupport should be provided in real time. Nothing is more frustrating than not having a way to contact the clearinghouse or finding out that you only get an email that a ticket has been created. Do they give you a real person to speak with? 
  • Eligibility Verification - The clearinghouse should provide real time eligibility verification that can be run prior to your patients walking through the door. This allows staff to determine those who are not eligible and reach out to patients before they are already in the office.
  • Claim Status Reports - Know the status of your claims. Your clearinghouse should provide you with same day claims receipt verification. And for that “Claim not on file” rejection, the system should provide you with proof that the payer received the claim and a mechanism to notify the payer that their rejection is incorrect. 
  • Rejection Reports - Claim rejection reports should be clear and easy to read. 
  • Printed Claims - You should have the ability to easily convert electronic claims to a printable format. You should also be able to view the claim, and verify immediately if any information is missing that will delay processing and payment when following up with payers. 
  • Data Storage - Many clearinghouses delete your claims history within a short period of time. There are benefits to compilation of data over time for claims trending purposes or if a payer demands the return of funds. 
  • Ease of Use and Access - Be sure the system is easy to use and accessible to your staff when they need it. Ask how the clearinghouse will communicate with you if there is a problem at the payer end - for instance, in their ability to receive claims data or verify eligibility.
  • Add-on Features - Make sure to find out what features are standard with the clearinghouse package. Ask if multiple options are available to make sure the system fits your needs. Add-on features can be beneficial and provide savings through more efficient operations. These add-on features might include statement processing so your staff are not printing and mailing statements, lockbox services, claims dashboard, and claims scrubbing.
  • Proactive Revenue Controls - Don’t be surprised. Ask if your clearinghouse support includes any controls that provide you with the insight to know when things are going wrong before your revenue takes the hit. 

In the end, your clearinghouse should provide you with value added services, not headaches that create more problems. After all, aren’t we facing enough challenges in the health care arena without adding your claims clearing to that list? 


For more information, contact Holly at MckayBurnetteSolutions@gmail.com.

The information, views & opinions presented in the above guest post are those of the author, who is solely responsible for all content, and do not necessarily reflect the opinions & views of FQHC Link or FQHC Associates.