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Medical claims clearinghouse: must-have qualities

Imagine all the hospitals in the U.S. — that’s more than 6,000 organizations. Now realize each uses a different medical claims clearinghouse to work more than 900 different insurance carriers. Each with unique infrastructure working across 50 different states, all with specific regulations.

Mix it all together, and you have the perfect recipe for an information catastrophe.

Consider this. If on average roughly 6K hospitals send just 10 medical claims per day to five different insurance companies, that adds up to 300K insurance claims sent daily.

Now compound that.

Take those 300K claims. Then factor in the phone calls and resubmissions each error or denial produces. Depending on the claim, that could easily be 10 resubmissions or 100 calls, because ultimately it’s impossible to precisely predict what that number might be.

And that continues on and on until all reimbursement issues are resolved and the bill is finally paid in full.

What is a medical claims Clearinghouse?

Devised by Medicare and large insurance payers to pre-screen for claim errors and act as air traffic control for submissions, medical claims clearinghouses are in charge of processing trillions of transactions each year and managing mountains of electronic information.

The more efficiently your clearinghouse processes and returns your information, the faster you get paid. The faster you get paid, the more payments you can collect.

In this article, we’ll explore the five essential qualities to look for in choosing your next claims clearinghouse.

1. Knowledgeable, prompt client support

You need a clearinghouse that allows you to log inquiries 24/7 and delivers timely responses. Waiting multiple days for an issue to be resolved creates payment delays and unnecessary costs.

But how can you tell if the clearinghouse you’re considering offers high-quality support?

  • Look for immediate (or at least prompt) acknowledgment and inquiry responses during your research period
  • See who others in the industry recommend
    • Current customers will usually tell it like it is, they’re not trying to sell you on anything, and they have personal experience to draw on
  • Verify that support teams are trained and operate in-house
    • While some companies outsource client support to save on costs, a high-quality in-house team can provide knowledgeable and aligned support

2. Quick status checks

Once you submit a claim to your clearinghouse, you should know within minutes if it went through or if it needs to be corrected and resubmitted.

The longer you have to wait for a claim response, the longer you’ll likely have to wait for a status update down the road. The longer you have to wait on any step in the billing cycle, the more potential revenue is left on the table.

3. Accurate, actionable claim information

Wasted time is wasted money. It’s not enough to just have the information in your system. You need to be able to efficiently access and use that information across work queues and staff.

Look for a clearinghouse with the ability to give you a claim status summary on an 835. This allows your staff to immediately identify which payments to post, which to leave, and which to reprocess, eliminating duplicate work, unnecessary account touches, and time lost looking at individual claims.

4. Usability

Choose a claims clearinghouse with easy-to-use features that also provides detailed, customizable reports and only requires minimal clicks to complete tasks. It’s essential to be able to quickly train your staff on the system to maximize the technology’s (and your staff’s) potential.

As the industry pushes for greater efficiency, it’s even more important for your business to save time and money while scaling resources.

5. Single-instance technology

Some clearinghouses offer platforms comprised of a variety of solutions they’ve aggregated over time. Unfortunately, sometimes they neglect full integration and continue using separate logins and interfaces.

Aside from the time wasted logging into separate systems, there are plenty of instances where things can go wrong or break if the tech is not truly consolidated and unified.

A single-instance, cloud-based technology suite should simplify workflows and support automatic updates. As both your organizational needs and technology evolve, you’ll ideally be able to access new, better solutions in the same unified platform.

The wrap up

Choosing the right claims clearinghouse can make all the difference. See what a truly unified Claim + Payer Payment Management platform looks like.

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