Medical Billing Clearinghouse Considerations

A Medical Billing Clearinghouse is basically a middlemen that takes electronic medical claims information, checks the claims for errors, edits the information into a standard format and then sends that information electronically to the insurance companies that they are contracted with.

It is extremely important that you choose a medical billing clearinghouse that is contracted with the majority of the insurance carriers that your Doctors use most often to ensure that your claims will be handled electronically from start to finish. If you send a claim to a clearinghouse and the insurance company that you are trying to send to is not on their list, then the clearinghouse will have to drop the claim to paper and mail it for you for an additional fee which is typically higher than you could do it yourself. You should be able to find a list of all insurance companies that the medical billing clearinghouse is connected with on the clearinghouse's website.

What Else To Look For In a Medical Billing Clearing House?

COMPATIBILITY:

Be sure to check with each medical billing clearing house to make sure your software is compatible with theirs. Since no single standard for medical billing software exists, not all software programs are compatible with those used by clearinghouses. Also, make sure you are able to send claims by modem, not just over the internet.

CUSTOMER SERVICE:

You should expect free and unlimited customer service by phone and email. The next area of concern should be: will a live person answer the phone or do you regularly get directed to voice mail? If the latter, how quickly do they return return all phone calls and solve your technical support issues?

CLAIMS ACKNOWLEDGMENT REPORT:

The ability to check the status of all insurance claims submitted on line should be expected. Another beneficial feature would be the opportunity to edit and correct your claims online.

ELIGIBILITY VERIFICATION:

This service confirms if a patient is eligible for medical insurance benefits. It also allows you to check the patients co-pays, deductibles, maximum number of visits per year and if authorization or referral from a primary doctor is needed.

ELECTRONIC REMITTANCE ADVICE:

An Electronic Remittance Advice(ERA) is basically an electronic version of the Explanation Of Benefits (EOB) that the insurance company would send with a copy of the check owed to the provider. With more insurance companies utilizing Electronic Funds Transfers (EFT) it is also very helpful, if not mandatory, to receive the EOB's electronically as well.

PATIENT STATEMENTS:

Printing, sorting, and mailing patient statements is a very labor intensive process. Some medical billing companies insist it ends up saving them money. We have talked to other billing companies that prefer to do it themselves so they are able to add personal notes to the patient statements. Several owners have also pointed out that there is not much additional labor expense to doing the patient billing yourself as long as you have your staff stuff the claims while they are sitting on hold with the insurance companies.

COST:

The cost of doing business with a medical billing clearinghouse varies considerably between clearinghouses and making a side by side comparison is difficult since very few companies structure their fees in a similar format. For example, some charge a flat fee per medical provider while others charge a fee for each claim filed. Some clearinghouses also have additional charges such as an initial setup charge, monthly fees, etc... Before you sign up with a medical billing clearing house, make sure you understand all of potential "junk" fees before committing to a single clearinghouse. Be sure to compare all aspects, not just the price.

A Medical Billing Clearinghouse usually gets paid by most commercial insurance carriers with whom they file the claims, with the most notable exceptions typically being the government carriers such as Medicare and Medicaid, as well as Champus and Blue cross/Blue Shield. With this in mind, you should look for a clearinghouse that does NOT charge you for commercial claims and only charges you a reasonable fee (if you're lucky you may find some under 20 cents per claim) for filing claims to the insurance companies where they do not receive a fee, such as the government carriers. You will typically find that paying a flat monthly fee per doctor will onlywork in your favor if your provider bills a large number of claims to Government carriers.

The majority of clearinghouses will also drop any claims that cannot be submitted electronically to paper and mail them for you. Some offices prefer this method because they can just batch the claims and send them to the medical billing clearinghouse with their daily electronic submission. There is no printing, stuffing envelopes and mailing. In the past we have found clearinghouses that charge a per claim fee around 45 to 60 cents.

Many experienced medical billing companies prefer to print and mail the claims that do not go electronically themselves. While 45 or even 60 cents a claim may sound like a good deal, remember that you will often have three or four claims going to the same insurance company, which will allow you to put all of them in one envelope with a single stamp, resulting in a per claim cost of closer to 15 or 20 cents.

As you have probably already realized, you should be especially concerned if your PC based software vendor or web based software supplier only offers one clearinghouse option. If you were to become dissatisfied with the the service provided by the clearing house or the fees they are charging, then you would be forced to accept the unreasonable fee structure or change your billing software in order to have a better selection of medical billing clearinghouses.