Clearinghouses used to be the silent partner for many health systems’ revenue cycle teams. They would sit in the background and be your gateway to claims submission to your payors. Transitioning from one to another was an onerous task and one that was not done often.
But over the last few years, and specifically in 2024, clearinghouse partners have moved to the forefront in helping manage RCM operations and have been the linchpin in numerous processes. Because of cybersecurity and data breaches this year, revenue cycle leaders now fully understand that clearinghouses are far more involved in their shop than just submitting claims. Several large breaches this year have shut down some vendors and made it impossible for health systems to submit claims or get access to their incoming payments, as clearinghouses also help with managing EFT payments. This has caused large hospitals to pivot to new partners in record time, often coming online in 2-3 weeks.
Have you reflected on clearinghouse partners? What are the considerations to think about when looking for a new partner?
Customization
It is important that a new partner allows customizations to fit your needs- are they able to create solutions to your unique problems, or are you getting a one size fits all approach?
Payor Connections
How many of your largest payors have direct links to your new clearinghouse? With payors using clearinghouses as well, this is vital if your if your large payors have “links” on both ends.
Likewise, does this partner have the correct connections with your payors to utilize 276/277 responses to speed up the claims adjudication process? Some vendors don’t have the correct connections with your important payors, so they don’t return the correct data at the correct time. 277 responses become proprietary data and are not actionable.
Clean Claim Rate
What is their clean claim rate with other their other health system partners? The focus should be on reducing payor rejections, not managing them.
Bundling Services
What other services do you need? It is important to note which services your clearinghouse partner can offer at a better price or more efficiently. Maybe you need them to help post electronic payment files, offer statement services, or help collect patient payments via an online portal. Some partners can help you avoid processing fees leveraged by some payment reimbursement solutions. Considering which services you need and how you can bundle them will help you run operations more efficiently, saving you time and money.
Real Time Eligibility
Do they offer Real Time Eligibility (RTE) or eligibility verification?
Reporting and Analytics
What level of reporting and analytics do they offer? The ability to drill down to payor specific rejections and payor returns, and create up front edits to catch and fix issues before claims are submitted is integral to an efficient timeline. Are these services an additional fee, or additional subscription?
ERA/EDI/EFT Enrollment Processes
How long does the ERA/EDI/EFT enrollment process take? An additional important consideration is being sure that you have all the correct network logins, admins and banking information ready for this process. In many cases, these could have been set by someone who has left the organization and were “set it and forget it”, and now, they need to be updated, and no one has the admin logins to access what is needed. Without this information, your EOBs and remits are coming on paper, which is inefficient.
Integrations
Are claims worked in your native patient accounting system, or do you work claim corrections out of the clearinghouse vendors web portal? If you are working out of the clearinghouse portal, does it automatically update claims back into your patient accounting system? Again, these small details help you to have effective systems and processes, so they are relevant to consider when choosing the right partner.
Pricing
What is the pricing structure? Does it allow for future growth or is it a flat rate? Are you charged per transaction, or are they bucketed into groups? Considering each partners pay structure is critical when comparing it to your unique needs.
Conclusion
While this list is by no means all inclusive, it can act as a guide of questions that should be asked and evaluated during a clearinghouse transition. We know that vendors have lots of moving parts and are involved in many different processes in the revenue cycle. Choosing who to invest in is a big decision.
Healthrise is a partner that seeks to partner with you holistically. With Healthrise by your side, you can trust in a partner who is fully invested in your success. Our comprehensive solution offerings reflect this commitment, encompassing strategic consulting, EHR support, revenue cycle management, and innovative technology solutions.
Are you interested in learning if Healthrise is the right partner for you? Connect with our experts today and uncover how we can customize our solutions to fit your needs.
Author: Ryan Bell, Consulting, Healthrise.
