How to Choose The Perfect Medical Claim Clearinghouse in 5 Easy Steps

If you mentioned the word “clearinghouse” to a healthcare professional, you would get one of two reactions. The first, most common reaction you would receive is a sigh followed by an eye roll. The second and rarer reaction is a smile and verbal acclaim.
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Even though clearinghouses are such an integral part of the modern medical landscape, there’s a reason why the most common reaction to them is negative.
You see, the healthcare industry as a whole grew to a $4.1 trillion industry in 2020. Since it’s such a gigantic industry, insurance payers and large medical claim clearinghouses put up guardrails to try make the management processes involved easier.
To make that last statement easy to understand, calling a large insurance provider or clearinghouse is a similar experience to calling your internet services provider.
The number you dial leads to a robotic filtering system that never understands your responses because it’s bad at listening. After you get through repeating yourself to the robotic system, you’re left waiting on hold for hours at a time because their “system is experiencing heavy traffic”. Yes, I’ve gone through this personally and am still bitter about it.
But it doesn’t have to be this way.
Healthcare providers have a choice as to which clearinghouse they work with. And believe it or not, not all of them have the same hair-pulling experience that the majority of us have grown accustomed to.
The first step towards choosing the perfect medical claim clearinghouse starts by understanding the process.
Before you start feverishly googling for the perfect medical clearinghouse partner, the first step you need to take is ensuring that you understand the claim submission process.
Although I think it’s safe for me to assume that by reading this blog post, you’re familiar with the claim submission process. It’s the most important piece to understand when trying to find the right clearinghouse. So, I can’t chance that.
However, I won’t bore you and go through the entire step-by-step process.
Instead, I want to harp on the fact that there is a lot of jargon and acronyms involved with this process.
If you haven’t brushed up on the terms associated with sending claims to insurance providers, you’ll need to re-familiarize yourself with them.
Specifically, refresh on terms like appeals…denials…electronic remittance advice or ERA…ANSI…Current Procedural Terminology or CPT… and Explanation of Benefits or EOB.
The reason why you’ll need to keep the meaning of these terms in your backpocket isn’t entirely because it’ll help your knowledge. You see, once you start evaluating partners, they’re going to bombard you with all of the terms I listed earlier as a part of their solution’s demonstration.
If you don’t understand all of the terms these clearinghouse sales representatives mention, you won’t get much value out of them. It’s hard to evaluate medical claim clearinghouses if you don’t understand the entire process and vernacular that’s used.
The second step is to evaluate your organization’s needs.
We’re still in the preliminary stages of choosing the perfect medical claim clearinghouse. At this step you haven’t reached out to anyone yet.
Not only are the terms associated with the medical claim submission process something that you need to brush up on beforehand, you also need to understand the needs of your specialty.
You see, things change a little bit based on your niche within healthcare.
For example, if you’re the owner of a mental health practice, you’re going to have to work with managed care organizations (MCOs). Similarly, if you’re a dentist the requirements placed on you by the payer are going to be different than what’s required for submissions from pediatricians.
Yes, there are still similarities…at the end of the day each of the healthcare organizations submitting claims are trying to get paid. But, the small differences have the biggest impact.
If you don’t know that key differences exist in the claim submission
process for your specialty, you might end up with a generic clearinghouse partner.
Let me refer back to that mental health practice example from earlier. If your organization resided in Ohio, in this instance, you’ll want your clearinghouse partner to be an expert on the Ohio Medicaid redesign.
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