A clearinghouse in the healthcare billing world is an organization acting as an intermediary forwarding claims from healthcare providers to insurance payers. The clearinghouse assures a smooth transition of data for payment to be received for services rendered. The core function of the clearinghouse has traditionally been to scrub claims before delivery to the payer and, over time, a few select clearinghouses have mastered this process and remain unchallenged.

That is until consumers began purchasing revenue cycle systems geared specifically toward their healthcare specialty like TELCOR RCM. TELCOR RCM provides scrubbing much sooner in the process, providing the consumer more control over their edits and visibility to redefine their business practices.

With claims scrubbing no longer a major selling point for many clearinghouses, these vendors have started to rebrand themselves as RCM solution vendors. Much like other companies reinventing themselves, such as IBM going from PC distributor to IT services, or Netflix going from DVD merchant to streaming service, or even MTV transitioning from music television to whatever they are now, companies have to diversify their services.

To help navigate the various services clearinghouses provide, here are some key considerations when evaluating or contracting with a clearinghouse.

General Considerations

When selecting the right clearinghouse for your organization, it is important to evaluate if the clearinghouse has a successful track record processing laboratory claims specific to your type of testing.

Additionally, to minimize your clearinghouse costs, consumers should determine which payers they can go direct to rather than paying the clearinghouse per transaction to deliver the claim. Once an agreement is in place with the clearinghouse, make sure it’s understood what “bridge routines” are in place. These edits may be redundant to what your true laboratory-specific RCM solution provides in terms of edits and can slow the throughput of claims. Otherwise, your clearinghouse should simply be a conduit routing many claims to various payers and return the remittance back to your RCM system.

Claims Management Services, You May Already Have them

Generally, billing staff should not have to access the clearinghouse to complete daily billing functions. If you already leverage a clearinghouse, a good practice is to evaluate activities your staff may be performing at the clearinghouse and determine if an integrated solution already exists with your RCM application.

A true RCM solution, much like TELCOR RCM, should provide the tools necessary to analyze, organize and tackle denials and appeals in dedicated online workqueues allowing your billing team to be productive and remain in one system. If staff are accessing the clearinghouse directly to assist with denials, appeals, claim status, or even analytics, contact your RCM vendor to see if these practices can be optimized for your organization without logging into the clearinghouse’s portal.

Diversify then Verify Eligibility

A clearinghouse can serve as a great conduit to deliver and receive batch or real-time eligibility requests to and from your true RCM solution to many payers. Keep in mind, when it comes to eligibility, consider diversifying. If your clearinghouse does not provide a 270/271 connection to all payers, you can contract with a second clearinghouse for the missing connections and leverage your RCM solution to transmit insurance verification by payer to different clearinghouse vendors.

Portals, Statements, Credit cards, Oh My!

Much like with claim management services, patient pay services that clearinghouses provide may already be available through your RCM vendor. Keeping these services on an island at your clearinghouse rather than integrated through a revenue cycle system can be costly.

For example, with an integrated credit card module and patient or client portal via your RCM solution, changes made to patient accounts or payments are kept in lockstep. Meaning your reports are accurate, timely, and customer service staff are best equipped to field calls or follow up when required.

With patient statements, the name of the game is cost. Be sure to shop around and entertain contracting directly with the print and mail vendors your own clearinghouse leverages to secure better wholesale pricing.

Wrapping It Up

As a consumer selecting a clearinghouse, it’s important to enter the process knowing exactly what is needed and what is important for your organization. Be careful not to overpay or leverage a redundant and inefficient service.

As a general starting point, find a tried and true clearinghouse with a solid track record processing laboratory claims and only start with the basic services. If you find there are more services you want to entertain, first verify with your RCM vendor to determine if an integrated solution already exists and look to centralize as much of your billing functions as possible.

Kwami Edwards
Chief Customer Officer

Kwami Edwards, Chief Customer Officer, RCM, has more than 15 years of health care experience with a strong background in workflow redesign and change management.  In his current role, Kwami works with owners and executives to help ensure successful implementations and continued reengineering support.