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The healthcare industry continues to grow and transform which has pushed healthcare providers to constantly adapt to these new standards. This is something that healthcare providers must remember when picking a clearinghouse to assist in the processing of insurance claims. Why do healthcare providers need a medical clearinghouse?

As a reminder, a medical clearinghouse fulfills an intermediary role between healthcare providers and the insurance companies who ultimately provide payment for submitted claims. These clearinghouse companies take care of a process called claims scrubbing, which means they review all submitted insurance claims for errors. This includes verifying that the CPT codes are correct and that the varies codes and modifiers are appropriate for that procedure. The goal of claim scrubbing is to eliminate costly processing mistakes that lead to rejected or denied claims.

With this important goal, all medical billing clearinghouses must constantly update their information in order to operate effectively and help optimize the revenue cycle healthcare practitioners who are using these services. New challenges are changing existing healthcare industry models such as the shift from a fee-for-service to a fee-for-value, MACRA, the expansion of increasingly sophisticated software, off-shoring of services, etc.

In a rapidly shifting landscape, a clearinghouse must meet the needs of the healthcare providers who rely on this service in order to correctly undertake claims scrubbing, processing of claims and receive insurance payments. With clearinghouses fulfilling such an important role, it can be a daunting task to pick or evaluate these services. To help streamline this task, here are three general questions to consider:

[1] Customer support and service:

Initially discovering whether a medical clearinghouse has good customer service is a challenge. Investigate online reports, reviews as well as find other medical practitioners who have used the clearinghouse’s services. A major problem with some medical clearinghouses is that they are difficult to get a hold of or slow to respond to customer service request. This is a bad sign since a clearinghouse should help solve problems, not create new ones. Quality customer service and support is a must, otherwise insurance claims are hindered and timely filing limits become a concern.

When a clearinghouse’s claims scrubbing function slows down, the revenue cycle of the medical providers who rely on the clearinghouse services also slow down. Well-organized medical billing departments are focused on denial management and prompt reimbursements. The level of customer support should provide meaningful value to a medical practice. If health professionals feel like their medical practices are working for the clearinghouse, instead of the clearinghouse working for them – these practices should look for a new clearinghouse.

[2] Interface, security and functionality:

Healthcare providers need to have a clear vision in regards to what they need for their medical practice. Do they want a clearinghouse that has streamlined user features, or do they desire one that has additional capabilities but has a steeper learning curve for new users? What level of integration is needed? Are additional features beyond claims scrubbing needed such as insurance verification, patient statements, claims management analysis, etc. Will the medical clearinghouse act as a standalone solution or is it one of many software interfaces? Having an integrated system that includes practice management, EMR or a hospital information system is convenient for workflow.

However, if one portion of the system stops working for some reason — everything may fail! For security, some medical providers purposely divide up their clearinghouse, EMR, billing database, etc. This provides a layer of security so if their practice management software crashes, they still have access to other critical software and databases. Also, if they ever grow tired of their existing clearinghouse, it is easier to change companies without losing access to web portals and interfaces that are necessary for day to day operations.

[3] Productivity and Future Goals:

Ideally, medical clearinghouses should quickly increase the productivity of the healthcare provider’s back office. Yet, the medical clearinghouse should have the capability to provide increased features as the needs of a healthcare professional change. As a practice grows in size and complexity, the clearinghouse should be able to meet these new demands. Can the existing clearinghouse easily connect to other vital software and systems? If a clearinghouse’s web interface has to constantly be rebuilt in order to connect to other support software, this is a problem.

Health professionals should set realistic one, three and five-year goals. So as a medical practice grows, so should the capability of the software. The more information healthcare practitioners have access to, the easier it is to make decisions. This includes knowing how easy it is to scale up (or scale down) the workload through a clearinghouse.

Healthcare providers are unique, so they should adopt the clearinghouse that is the best fit for their needs. In the end, the clearinghouse should work for the healthcare professional instead of the other way around.

Please reach out to ABCS RCM for any additional questions about medical clearinghouses? CONTACT US

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