Around 4 million healthcare professional and medical billers using their own systems send claims to over 4,000 different insurance carriers in 50 states, every day. This amounts to tens of millions of claims daily and trillions of transactions annually being sent to medical billing clearinghouses all across America!

Who needs it?

You do, of course.

Clearinghouse Benefits

The most efficient clearinghouses provide an extra level of claim intelligence that works from a financial perspective as well as for the effectiveness of your office staff.  The benefits include:

• Reduction of your payment cycle because claims are rapidly processed
• Simplification of claims processing
• Providing a single location to manage all claims
• Allowing you to fix errors in minutes rather than weeks
• Higher claims success (fewer claim rejections)

The Workings of a Claims Clearinghouse

After the billing software on your desk creates the electronic claim (or file) it is uploaded to your clearinghouse account. The clearinghouse’s main job is to review or “scrub” the claim for errors. The clearinghouse then transmits the file to the specified payer. That payer has already established a secure connection with the clearinghouse complying with the strict HIPAA standards.

You are notified by a status message whether or not the claim has been accepted or rejected by the payer. If rejected, you can make corrections and resubmit the claim. When accepted along with the patient’s valid insurance, you will receive a payment check and the EOB.

Going Direct

Many large payers such as Cross Blue Shield or Medicare act as their own clearinghouse. That means you can submit the claims to them directly without paying a clearinghouse fee.  While that may seem attractive, here are some factors to consider prior to making a decision to go direct:

• There may be extensive systems compatibility testing that may take weeks or months to complete before you can begin submitting claims.
• Your staff will have to remember multiple transmission methods which means multiple logons, file names/types and the error codes of each system.
• You may have to purchase additional software to comply with each payer.
• Support may not be as accessible as you would like in the event of difficulties.
• The lack of centralization means claim information and other data resides at many different locations.

Depending on your situation (if you just accept one or two insurance carriers, for example), it may make sense to go direct. In other cases such as a practice with multiple insurances and a heavy claim volume, it may make sense to use a centralized clearinghouse.