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The Role of a Clearinghouse in Medical Claims Processing

In the process of medical claims, there are those companies described as intermediaries or middlemen, with the function of forwarding the claims information from the healthcare providers to the insurance payers. Named as the clearinghouse, these companies work by checking the claim for any presence or existence of errors, in the process verifying if the same is in fact compatible with the software used by the payer.

Likewise, it is the clearinghouse’s responsibility to be certain that the procedural and diagnosis codes to be forwarded are valid and that every aspect of the procedure code is indeed compatible with the diagnosis code submitted together with it. The idea behind this scrutiny is to make sure that processing errors, which can be very time consuming are avoided.

Since you’re the healthcare provider planning to hire a medical claims clearinghouse, it is your right to choose one that you think will help you the most. But you do have to remind yourself that most clearinghouse companies will be charging you for each claim successfully submitted plus the additional costs involved in the process, such as sending a paper claim to the payer. There are two ways for claims to be sent; first is when the clearinghouse will submit them to the payers directly, and second is when they’ll send it via another clearinghouse’s site before actually reaching the payer. The most notable reason why some claims will have to be submitted through another clearinghouse is because there are times when your own billing software is not compatible with the processing software of the payer. Because of the risks and difficulties involved in having an incompatible software, it is very common for clearinghouses to require an enrollment period right before sending claims for the first time. This period meanwhile could last for about three to four weeks and in which the clearinghouse will be testing the compatibility of your software to that of the payer’s.

But you should know that the process is actually intended to avoid medical claims from being delayed, implying that it is for your own benefit in the long run.

But in the event that you observe that the clearinghouse you’re enrolled with does not make the effort not to send the claims to other clearinghouses every single time, it probably is best for you to look and shop for someone else out there. There’s no problem with a clearinghouse that will subject you to a transition period, but it no longer makes sense if you’re put on the same setup forever. Yes, it may be true that hiring a larger company will cost you more, but in the end, it’ll be worth it considering that you’d be expecting to receive payment off those claims on schedule every single time.
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