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Etactics' Whiteboard Educational Series - Episode 4: Medical Clearinghouses

Think about how much information your doctor’s office has to digest within one day. Let’s say it’s a small healthcare provider that sees an average of 20 patients on any given day. Each of these patients has different health insurance’s that all process and respond differently. Now imagine how many patients have different health insurance’s in a larger practice or even a hospital, the numbers add up quickly. 

How can a small one to two doctor practice find the time to not only see patients but also handle their claims and process them through different health insurances? Medical Clearinghouses function primarily as intermediaries who forward claims information from healthcare providers to insurance payers. Each provider chooses which clearinghouse they want to use for claim submission.

There are certain reasons why medical organizations should use a clearinghouse, these reasons are based on the following...

  1. Healthcare organizations, especially smaller practices, cannot afford to spend the labor hours manually uploading insurance claims. Clearinghouses specialize in uploading and send claims in bulk, all in one place. This increases both the speed at which your claims are processed and overall efficiency based on the shear volume that can be sent.
  2. To achieve pin-point accuracy, medical clearinghouses implement claim scrubbing rules to ensure that bad or incomplete claims don’t reach the payer. If this was done without a clearinghouse, it would increase the margin of error. Especially for the more detailed claims.
  3. Ultimately, the main goal of a medical clearinghouse is to get a claim paid as fully as possible. Claims are a beast all on their own, take the responsibility off of your workers and entrust it into a clearinghouse that is professionally trained in dealing with claim management. 

Medical clearinghouses may submit claims directly to the payers or they may send a claim through other clearinghouse sites before reaching the payer. Providers may choose certain clearinghouses over others based on the following factors:

  1. Cost. Pricing is always a top factor for any customer, it’s no different when determining which medical clearinghouse is the best fit for your organization.
  2. Availability of payer connections. The more compatible a clearinghouse is with payers, the easier it is to process claims through them.
  3. Built-in integration with various other hospital information systems or practice management systems. This is similar to the last point, integration is key when it comes to medical clearinghouses.
  4. Quality of value add programs. Everyone likes additional features. Some clearinghouses focus more heavily on the value add programs like reporting and workflow to make the entire process easier to analyze and complete.

From a broad standpoint, medical clearinghouses exist to help healthcare organizations receive payment in full from services rendered. There are many different clearinghouses out there and determine which one best suits you requires you to evaluate which of the facets of a clearinghouse are most important to you.

At Etactics, we provide a medical clearinghouse called IntelliClaim. Our clearinghouse helps customers solve problems through claim scrubbing, eligibility verification prior to claim submission, in-portal claim editing, and workflow automation.

For more information on IntelliClaim or medical clearinghouses, click here.