How Clearinghouse Operates for Payors and Medical Providers
Medical billing is an essential facet of the healthcare industry that ensures timely and accurate...
A clearinghouse facilitates the submission of medical claims and related data to insurance companies and other claims administrators. This includes electronically processing all of the medical details related to the claim in the ANSI format required by the insurer. Clearinghouses help rule out processing errors to expedite faster payment from the insurer.
Workers’ compensation and auto no-fault bills are not normally as high volume as standard medical claims that providers and payors manage but are equally important. However, these types of claims are often rejected by payors because they are missing required information that medical staff may not realize is required for these specialized bills. These rejections can significantly delay the payment process. A clearinghouse can help providers catch insufficient information upfront allowing cleaner, more complete, first-submission bills that decrease rejections by the insurer.
If claim processing takes a considerable amount of time, then it will naturally cause delay in the payment process. To help avoid such issues, choose a medical claim clearinghouse that has an excellent customer support system. Data Dimensions provides you with a dedicated Customer Support Manager to assist you, as well as a robust Support Center with an online ticketing system for fast triaging and resolution of inquiries.
Knowing where a claim sits in the process is important. First the provider will fill out the claim in their medical billing system. The medical billing system then sends the claim to the clearinghouse for processing. The clearinghouse will release complete bills through to the payor or alert the provider outlining what information is insufficient on each bill. Providers can check on bill status at any point. Therefore, a quality clearinghouse will provide transparency into where bills stand in the process.
The best clearinghouses work with numerous insurance providers and have most of them on their list of payors. However, a newly formed company or small clearinghouses may not have an extensive payor list and may not have connections that benefit you. Ensure that your EDI Clearinghouse has a robust payor list with your insurance partners to receive the greatest benefit.
The clearinghouse must have an easy-to-navigate user interface portal where you can check which bills are accepted or rejected and those that need re-submissions. The portal modules should be quick to understand and interpret.
Check the time it takes the clearinghouse to finish the bill and attachment (medical records) data edit/validation process. This process should be quick and accurate, as the more time it takes, the longer it will take for correcting/resubmitting bills and receipt of payment. A quality workers’ compensation and auto no-fault clearinghouse will offer a robust attachment to bill match method, and edit and delivery options since providers handle and store attachments in multiple different manners.
These edits will allow providers to select the most efficient attachment match method based on current workflow and storage systems, while the attachment edits suspend bills until an attachment is supplied. Ask what notification edits are in place when a claim is rejected, and what the workflow is to remediate the suspended or rejected bills. Having a quality edit/validation engine and Work Queue process removes much of the burden from providers.
Medical providers need clarity about the working methodology of a workers’ compensation and auto no-fault clearinghouse, its performance, and how much they benefit from forming a partnership. Getting answers to your questions upfront is necessary to avoid any issues in the future.
The following are a few questions to consider before the partnering:
· How many bills do they process monthly?
· Do they offer robust Work Queue edits?
· Do they have an extensive payor list?
· How many direct payer connections do they have?
· How well-equipped is their customer support team?
· What are the additional benefits they offer over their competitors?
There are several important factors to consider when choosing a clearinghouse for the processing of workers’ compensation and auto no-fault bills. Medical providers need to pay attention to various aspects including their turnaround time, technological ecosystem, customer support team and more. It is advisable to dig deeper and do out-of-the-box research, something that is specific to your practice, before making the plunge!
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