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Why Your Office Needs the Right Medical Claims Clearinghouse

You are diligent in making sure your medical claims are clean and correct before sending them to the payer. You have dependable medical billing software to help ensure casual mistakes caught early on. You may have heard medical claims clearinghouses benefit healthcare providers, but wonder what they might offer that you don’t already provide. Is it worth the additional expense or something your practice can do without? Here are some of the reasons your office can benefit from choosing a medical claims clearinghouse.

Records Are Increasingly Electronic

Most likely you still send paper bills, but healthcare claims are increasingly processed electronically. Instead of claims going through the post office, Medicare and many large insurance payers prefer to use electronic clearinghouses to sift through claims looking for errors and submit them through the proper channels.

Clearinghouses send and receive large amounts of medical billing and claim data, and each submission or action can trigger a separate response. Software manages the procedure so it happens quickly and correctly. Medical billing departments can view and manage claims during any stage of the process from one location.

Improve Current Processes

Right now, you probably receive medical claims as a superbill. Your staff transfers that information to your billing software, prints it as a CMS1500 form and mails it to each insurance company.

Once it arrives, the insurance company looks it over for errors. If they find any, they send it back to you and your medical billing staff has to start over. If the claim is clean, they submit their part of the payment and you move on to billing the patient for any remaining balance. The whole process takes a significant amount of time and manpower.

Often, the longer it takes to bill the patient, the less likely they are to pay. The more times data has to be handled and input, the greater the likelihood of making a mistake.

Prevent Billing Problems and Returned Claims

Most of the time, claims are rejected or denied because of human error. Insurance companies return rejected claims to billers because they contain one or more errors and need to be corrected. Clearinghouses use scrubbing to make sure claims are not rejected.

Denied claims are ones the insurance company has processed and found unpayable. Sometimes billers can appeal the decision, but if the bill is for procedures not included in the patient’s coverage, appeals will not be successful.

The U.S. Government Accountability Office gathered data on insurance denials and found that insurers denied coverage more often because of billing errors and eligibility questions than because they disagreed with the necessity for the care the patient received. Doctors and other healthcare providers lose an estimated $125 billion every year because of medical billing issues.

  • Clearinghouses evaluate bills to check for the following errors:
  • Missing or incorrect patient data – A single error in the patient’s name, gender, birthdate or insurance number can lead to claim rejection.
  • Erroneous insurance provider information – if the payer’s contact information or address contains flaws, insurance might return the claim.
  • Inaccurate billing codes – If the Place of Service codes, HCPCS or CPT codes have confusing modifiers attached or digits are missing or transposed. the claim might be sent back.

Healthcare providers have also had claims returned for mismatched medical codes, forgetting to include procedures or diagnoses or submitting more than one bill for the same service. Other errors like undercoding, poor documentation and upcoding are a type of fraud and will also trigger rejection.

Medical Claims Clearinghouses Improve ROI

When healthcare providers use a good medical billing clearinghouse, their return on investment (ROI) dramatically increases. Your organization gets paid faster, which gives you an advantage over the competition. Here are several ways a clearinghouse improves your profits:

  • Once your practice submits a claim, clearinghouse software scours every line to identify errors you might have made during data entry. They identify errors in seconds and let staff know right away, while they are still working on the file. Not only do you reduce wait time from days to seconds, your employees find out about the error while the information is still fresh.
  • A clearinghouse stores information on individual payers in their system, so that data doesn’t have to be entered every time. Instead of re-keying data for every claim, it is electronically filled in for you. Electronic submission makes claims easy for the insurance payer to access.
  • Send all your claims at once instead of having to submit a separate file for each payer. Faster submission reduces the time it takes before you’re paid.
  • Your practice likely backs up data, but in the event of a natural disaster or unforeseen emergency, your clearinghouse can provide you access to any medical billing data you submitted before it was lost.
  • Save money on printing, postage and envelopes and leverage the fact your business is environmentally responsible with your clients. As people grow more conscious of environmental care, point out you care for the planet with the same dedication you offer your patients.

Why Not Go Direct?

Medicaid, Medicare, BlueCross and other large payers allow you to electronically submit information to them directly. You may wonder why you should hire a medical claims clearinghouse instead of going that route.

Submitting claims directly requires going to each payer’s individual website and keying in transaction data. Billing staff has to navigate multiple websites, keep track of separate passwords and learn error codes that are specific to each payer. Data is spread out over numerous locations and harder to track. Some payers require you to purchase additional software and provide little or no technical support.

Your practice ends up with wasted time, frustrated staff, high number of errors and frequent denials. It’s electronic, but it’s inefficient.

Apex EDI offers a larger payer list than any other service of its type. Thousands of practices use our software because its OneTouch solution provides a simple, cost-effective way to submit claims and receive quick reimbursement. Contact us to see how we can help you make more money today.

www.medicalbillingandcoding.org/potential-billing- problems-returned- claims/

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Apex EDI, Inc.
556 E Technology Ave
Orem, Utah 84097
Support: (800) 840-9152
Sales: (801) 383-0388
Fax #: (801) 642-0333
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