Use your clearinghouse to your best advantage.
A claims clearinghouse plays a crucial role in the revenue cycle management of a medical practice by serving as an intermediary between the practice and health insurance payers. A clearinghouse uses electronic data interfacing (EDI) to streamline the process of submitting claims to various insurance payers. It automates and expedites the submission process, reducing the time and effort required for manual claim submissions. Today, most payers mandate electronic submission and provide secondary insurance crossover, meaning the secondary insurance is also electronically processed following the primary payer’s claim adjudication. Medical practices should request specific functionalities and services from their clearinghouse to ensure claims are scrubbed and accurately sent.
Following are key requests practices can make to enhance the accuracy of claim submission.
STREAMLINED WORKFLOW INTEGRATION
Ensure optimized integration with the coding software that the practice uses. Clearinghouses can integrate seamlessly with practice management systems and other software used by medical practices. This integration streamlines the workflow by minimizing manual data entry, ensuring consistency between internal systems and the clearinghouse, and enhancing accuracy.
Clearinghouses can also assist with validating insurance information to ensure claims are submitted with accurate and up-to-date coverage details.
CLAIM-SCRUBBING SERVICES
Each year brings updated billing codes and guidance revisions to incorporate into your billing processes. Clearinghouses have sophisticated claim-scrubbing tools to enhance accuracy. Practices can request comprehensive claim-scrubbing services that identify and flag potential errors or issues in claims before submission. This helps prevent common mistakes such as missing information and coding errors, which could lead to claim denials or delays. Examples may include checking for appropriate codes, verifying the presence of demographic data, confirming that the diagnosis matches the code billed, identifying missing essential claim data fields, flagging provider credentialing issues, etc.
Clearinghouses can also check claims for compliance with National Correct Coding Initiative (NCCI) edits, which are sets of coding rules developed to prevent improper coding that could lead to overpayment. Identifying and correcting NCCI violations helps to avoid claim denials. Additionally, clearinghouses can detect duplicate claims to prevent overbilling for the same service, further reducing claim denials.
CUSTOMIZED EDITS, ALERTS
Ask for the ability to customize claim edits and receive alerts for issues relevant to the specific practice or specialty. Customization ensures the clearinghouse identifies errors based on the practice’s unique requirements and preferences. Examples may include an injection procedure code billed without an accompanying drug code, an incorrect place of service for a procedure code and modifier errors.
PAYER-SPECIFIC EDITS
Inquire about the clearinghouse’s capability to perform payer-specific edits. Different payers may have unique requirements, and customized edits by the clearinghouse for each payer can ensure claims are tailored to meet those requirements. An effective clearinghouse stays informed about individual payer policies and requirements to ensure claims are formatted according to each payer’s specific preferences and standards, reducing the likelihood of rejections due to formatting issues. This includes mapping codes to the appropriate, payer-specific codes and catching any discrepancies that may lead to claim denials.
Examples include a payer that requires a specific office visit code family only, missing required modifiers, flagging a differing commercial payer’s global period or when preauthorization is required by a specific payer for a particular service. Errors in verifying patient insurance benefits can also lead to claim denials.
REAL-TIME FEEDBACK AND CORRECTION
Ensure the clearinghouse provides real-time feedback on claim errors and allows for immediate correction. This feature enables practices to address issues promptly, reducing the risk of claim rejections and denials. Clearinghouses can also provide real-time updates on the status of submitted claims. This visibility allows medical practices to track the progress of successfully billed claims, identify any issues promptly, and take corrective actions in case of rejections or denials. Practices should designate a staff member to check for and correct rejections daily to ensure prompt billing and payment. Denials should be addressed quickly, either as they are posted or shortly thereafter.
EDI COMPLIANCE CHECKS
Request regular checks for EDI compliance to ensure electronic transactions adhere to industry standards. Clearinghouses should stay updated on regulatory changes and perform compliance checks to prevent issues related to the format and structure of electronic data interchange, further reducing the likelihood of rejected claims. This helps medical practices comply with evolving standards and regulations for claim submission and processing, leading to smoother and more reliable communication with payers. Clearinghouses can also identify incorrect payer IDs or addresses, further reducing reimbursement delays.
DASHBOARD AND REPORTING TOOLS
Many clearinghouses offer reporting tools and analytics that provide insights into claim submission trends, denial patterns and key performance indicators. This information empowers practices to make data-driven decisions for process improvement. Ask for a user-friendly dashboard and reporting tools that provide visibility into claim-scrubbing results, so your practice can monitor the effectiveness of the claim-scrubbing process, identify patterns and proactively address recurring issues. Use rejection and denial reports for training to continuously improve coding and billing processes.
TRAINING AND SUPPORT
Request ongoing training and support from the clearinghouse vendor to allow practice staff to maximize the benefits of the claim-scrubbing features. Training sessions can help staff understand available features to maximize utilization, address common issues, and optimize the claim submission process.
MAKE PRACTICE LIFE EASIER
In summary, a claim clearinghouse is essential for medical practices to optimize their billing processes, reduce errors, enhance efficiency and improve the overall management of the revenue cycle. It is a valuable partner in navigating the complexities of electronic claim submission and in communicating with different insurance payers. By actively engaging with your clearinghouse and making these specific requests, medical practices can work to implement robust claim-scrubbing processes, reduce errors and improve the accuracy of claims submitted to payers. Regular communication with the clearinghouse is essential to address evolving needs and stay informed about new features and best practices. OM
