By: Crystal Ewing
Billing departments continue to be pressed by daunting challenges as the healthcare industry transforms from a fee-for service to a fee-for-value business model. The question today, with an insurance industry that is more complex than ever, is whether your current clearinghouse is up to meeting these challenges.
Changes such as the Medicare Access & CHIP Reauthorization Act (MACRA) and the lifting of the freeze on new ICD-10 codes mean you can’t count on getting by with “business as usual.” Even with the delay granted for MACRA, you still need to be on top of this rapidly shifting landscape. Now and in the future, your organization’s ability to meet these new regulatory requirements will directly impact how much – and how quickly – you get paid, as well as your ability to collect payments.
So if your contract with your current clearinghouse is up for review, now is a good time to ask whether your vendor is still up to navigating today’s tumultuous healthcare billing seas. Here are key questions you should ask to determine whether it’s time to make a change:
1. What don’t you know?
If you don’t know the major revenue cycle issues your organization is facing, changing clearinghouses will just transfer them, not solve them. Yet with such a transformative shift, many billing departments still live in the blind spot of the Johari Window – there is so much information on so many different levels that affects reimbursement, it would be seemingly impossible to keep up with it all and still get the billing out. You want a clearinghouse that can help you identify problems and develop solutions.
2. How happy are you with your clearinghouse’s current level of customer support and service?
Across the industry, one of the biggest complaints is vendors are too slow to respond to support requests. Tickets remain open longer than they should, negatively impacting the revenue cycle. Or, in the context of clearinghouses, those calling in are told to contact the practice management vendor or the payer – as opposed to the clearinghouse reaching out on the client’s behalf.
You should also consider whether your clearinghouse offers the customer service and support that works best for your organization’s unique needs. Some billing departments want a hands-on, more personal approach. Others prefer digital trouble tickets, i.e. email or a portal. If your current clearinghouse offers only a one-size-fits-all approach, that’s a sign they aren’t that concerned with how their clients prefer to do business.
3. What type of functionality will you need from your clearinghouse?
Will you be using the clearinghouse just as a switch to connect with payer platforms, or as mentioned before, does it also need to integrate with your practice management or hospital information system? Also, do you prefer to do your own edits, or will you expect the clearinghouse to handle the edits?
As an example, many clients prefer a hybrid approach, using specific advanced features and workflow tools in conjunction with existing screens or systems. Others favor more of an integrated approach – one that provides a single end-to-end solution for the entire revenue-cycle spectrum:
- Eligibility verification
- Patient estimation
- Patient payments
- Claims management (including scrubbing, validation and missing claims)
- Rejection analysis
- Predictive analytics
Similar to the question of client support, you want to ensure your clearinghouse offers different forms of functionality to fit the business, from fully integrated to standalone. Because what if your business needs change?
4. How can the clearinghouse help increase your team’s productivity?
The table stakes for any clearinghouse should include efficiently submitting an 835 within a consistent, agreed upon period of time, so you can get paid quickly. All too often, however, the focus becomes getting good at managing payer rejections and denials – instead of reducing them.
So, when considering a change, you should find out if the clearinghouse can help identify and analyze the root causes of the denials and payer rejections while still making the edits and offering the workflow tools that can help you get paid more quickly and simplify the entire claims-management process.
5. How can the clearinghouse help with data integrity?
It’s easy to get lost in the sheer volume of healthcare data. Practice management, hospital information systems, imaging diagnostic systems and now wearables are all continuously producing health data – information that may need to be integrated into the RCM process. Each of these sources must be vetted and managed to ensure the data they’re producing can be trusted. Investigate how any clearinghouse you’re considering manages data integrity, both going in and coming out, to create a single source of truth for billing.
Many clearinghouses offer some of these capabilities; very few offer all. Yet these will be some of the most critical points as we move forward over the next few years – so also ask questions about what investments the clearinghouse is making, in addition to current capabilities.
If you’re at the point of considering a change, don’t rush the process, and don’t just settle for “better” than your current vendor. The answers to the five questions above will guide you in your selection – but continue to press for information so that you find the best fit for your organization.