Demand More from Your Claims Clearinghouse

February 01, 2021 By: Quadax

Flexibility, accountability and support are the differentiators of a high-performing revenue cycle partner.

Increasing financial pressure related to changing healthcare economic realities requires the pursuit of continuous improvement and streamlined productivity. To attain continuously advancing revenue cycle goals, every element of your business office system must be a high-performing contributor— especially your claims clearinghouse.    

While the clearinghouse market has reached a mature stage, with most players offering a fairly standard set of services, it is nonetheless true that all clearinghouse organizations are not the same.

“Some of the most significant differentiators as indicated by participants in this study are found within the service delivered by the various vendors in the market,” wrote researchers. “Some vendors do much better at providing high-quality service and support, which is almost transformative in moving the experience from a vendor/customer relationship to more of a partnership.”  ~KLAS Research

A high-performing clearinghouse accentuates the partnership aspect of a good business relationship by seeking to advance the mission of its client organization. The result of this sense of partnership will be greater responsiveness and collaboration with dedicated personal support, and creativity in developing and deploying solutions with full transparency and accountability. The best solutions will be flexible and highly-configurable, fitting the policies, methodologies, and business goals of the healthcare organization, rather than forcing them into a pre-set mold. 

Flexibility is a key feature of a high-performing clearinghouse and its electronic transaction management system.  Three of the many areas through which the flexibility of a system may be assessed are workflow, security, and the application of custom programming. 

  1. The workflow engine of a premier clearinghouse system will allow the provider organization to route work electronically among staff members and departments within the hospital or practice to facilitate robust collaboration in a fraction of the time that would ordinarily be committed to seeking input from other functional areas with paper worklists.
  2. A highly configurable menu of security levels is critical to allow the system administrator to assign specific access rights according to the organization’s own rules. Enforcing security policies is paramount for maintaining compliance with governmental and other regulatory agency standards.
  3. Though its most popular application is for claim edits and claim data conversions, custom programming can be beneficial in several areas of the electronic transaction management system.  These include file intake protocols, file processing, remittance file splitting, and reporting options. Custom development options available to the provider organization should comprise both developer-driven programming and client-driven programming.  Ideally, developer-driven programming to accommodate more complex logic and coded by the clearinghouse organization, should be completed in days, rather than weeks or more.

Accountability and transparency are the hallmarks of the best clearinghouse. Full accountability as to the state of the data and documentation of every data modification made, by systems or by users, is an essential feature of a high-performing electronic transaction management system and the clearinghouse organization that supports it. Accountability with regard to claim data requires that a full life cycle record, tracking every view and action associated with the data, be documented and permanently attached to that claim, linking related records as applicable.  The actions of system processes that apply claim data conversions must be clearly indicated to provide the audit trail back to the claim data conversion logic. And, transparency will follow through with a full accounting of data transmissions available to provider organizations at all times.

Accountability is further demonstrated through comprehensive, accurate reporting, and by the return of data for posting to the provider’s information system as well.  Using reported data on errors and error rate trending, the patient financial services staff will be able to move error correction upstream to the EHR system. This improves clean claim rate and staff productivity. Effective options for data exchange with information systems, imaging systems, and other third-party applications on the provider organization’s network enable efficient, accurate interoperability. These are easily implemented by a high-performing, EHR-agnostic, clearinghouse.

Finally, a high-performing clearinghouse will make it easy for a provider organization to implement its solutions. They use a proven, structured, and repeatable implementation process that allows for comprehensive testing to address every eventuality while being flexible enough to fit the needs of that provider organization. A premier clearinghouse will have specialized teams for setup, implementation, edit research and development, client support, and adequate resources for application development so that any conversion concerns may be addressed competently and unequivocally.

Despite the benefits available, the decision to convert to a high-performance clearinghouse can be a difficult one for many healthcare organizations to make. While conversion concerns are not unusual, they can be overcome with the right partner. Learn more in our white paper, “Are Clearinghouse Constraints Obstructing Your Revenue Cycle Optimization?” 

Let's take on the revenue cycle together!

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