Making a List (and Checking It Twice) for Your Claims Clearinghouse

December 17, 2021 By: Quadax

Cleaner claims and faster reimbursement is on every revenue cycle wish list.

If cleaner claims for faster reimbursement are at the top of your healthcare organization’s wish list, it may be time to consider making a claims clearinghouse change. If your claims first pass rate is less than 99.6%, then your claims processing may be hindered by an underperforming editing engine. As small as one percent improvement can represent thousands of claims, saving hundreds of follow-up hours. As you create your revenue cycle resolutions for the New Year, examine your claims to cash flow. Is the performance of your claims clearinghouse collecting you more revenue?

A key performance indicator (KPI) used by the industry to measure a clearinghouse’s performance is claims first pass rate—percentage of claims accepted for adjudication on initial submission.  Understanding what goes into achieving a leading claims first pass rate can help define expectations as the claims clearinghouse pursues the best path for reimbursement

Here is a list of what you should expect from a high-performance clearinghouse.

Automate and Streamline

Does your clearinghouse gives you the ability to collect more reimbursement with added efficiency and productivity? By automating your business rules, you can streamline your claims processing. Automatically account for each payers’ unique requirements and policies. Count on your claims clearinghouse to work with you to get it right at the start, making sure your claims reach payer adjudication the first time. 

Follow the Rules

Knowing what a payer requires can put your claims on the best path for payment. Payer requirements and policies are regulated by standard insurance plans, contracted engagements or government plans (Medicare LCD & NCD rules).  Does your claims processing engine access the most current industry rules and payer requirements? Is your clearinghouse vendor dedicated to maintaining an edits library? Does the library include automated BlueCard routing, Medically Unlikely Edits (MUEs), and Correct Coding Initiative (CCI) edits?  

Self-Help Editing Options

Starting with the strength of your clearinghouse solution’s industry and payer edits library, do you then have the option to add additional rules and edits to fit your business? When you need client-specific claim processing, the best clearinghouse solutions provide an easy, convenient editing wizard that puts you in control. It’s your business; they’re your edits. Self-help editing options can help you accelerate change. Why wait for your vendor to perform the custom corrective edits you know you need now.

Insight Into Your Data

To make informed decisions that support revenue growth and organizational goals, you need real-time insight to determine if initiatives are working together. Without this data and the ability to analyze it intelligently, how will you know about potential billing and workflow issues, payer and reimbursement trends, and the true financial health of your organization?

Your clearinghouse should have critical data analysis and evaluation tools to help your organization make more informed decisions regarding business models and monitor the strength of the organization. 

Client Support

Revenue cycle experts should provide routine, on-site visits (or virtual, screen-sharing visits, according to your needs) to assist with event creation and resolution, continued training, reporting needs, best practices and general issue resolution. Does your clearinghouse vendor give you the support you need when you need it? Do you have a dedicated account contact you can call when you need answers? And would you call them your claims management "partner?"

Since the financial health of your organization hinges on your ability to capture reimbursement quickly and completely, you cannot afford delays due to inefficiency or inaccuracy. Cleaner claims for faster reimbursement starts before the claim drops.  As you make your holiday wish list for your healthcare organization, consider taking a look at your claims clearinghouse’s performance. If you find it is underperforming in any of these areas, then it might be time to ask for a new vendor and turn it into the gift that keeps on giving! Learn how you can spend less time fixing problems and more time focusing on what really matters - your patients. Experience The Quadax Difference

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