Role of Clearinghouse in the Success of Your Medical Practice

What is a role of a Clearinghouse in the success of your medical Practice? from Kunal Jain on Vimeo.



Hello, friends and all you aspiring billers from around the world.

Well, this is another episode about billing, and I will be talking about the claim management process because that is one process that everyone connected with medical billing should know very well.

The claim management process involves sending data to the payers or the insurance companies in a manner such that all the information (you want to send) is transmitted accurately.

There is one important platform that I want to talk about, which is the ‘clearinghouse.’ The clearinghouse helps in sending data from the provider to the payer and helps us in receiving the data electronically from the payer to the practice management system which the provider uses.

Usually, every provider has only one clearinghouse. If for any reason, a provider is using more than one clearinghouse, there may be a possibility that they have multiple tax ID’s; however, typically for one tax ID, you can have only one clearinghouse.

Let’s understand what’s a clearinghouse. A clearinghouse is a standard platform or medium between a provider’s practice management system and a payer’s (which is the insurance company) practice adjudication system. It manages the entire claim submission process and the related workflows.

How many things can a clearinghouse manage? Here’s a quick summary –

  • When a patient visits your practice, the clearinghouse ensures that the eligibility verification check is done.
  • The second thing a clearinghouse manages is the claim submission process. In the last episode, we spoke about the ‘charge.’ Once the charge is done, we enter the CPT code, the ICT codes and enter all the 33 forms, the charge is submitted to the clearinghouse.
  • The third function that has just started at all the claim houses is tracking of the claim status. So, when a clearinghouse is linked to the payer, it also sends status reports of the claim back to the payer. It could be that the claim been adjudicated, or that the claim is pending, and further information is required from the provider.
  • The fourth thing a clearinghouse does is called ‘835’, which involves sending e-remittances back into the practice management system of the provider. E-remittances are the payment, or a denial, or an interim update informing the practice that the payer will get back to them in a few days.

So, these are the four major function that a clearinghouse performs which every biller should be aware of. For each of these functions, there is a report tied to the clearinghouse. Every practice management system has an area called the ‘claims management section.’ Normally, all these reports appear there.

Every practice management system has to be linked to a clearinghouse, and the clearinghouse has to be linked to the payer; this is kind of an EDI (electronic data interchange) set up. When you set up a new practice, typically this link is established by a billing company or the company handling the practice management software of the provider. Then in the future, billers can access the link by clicking some buttons within the practice management system.

Sometimes, a clearinghouse may provide a separate login ID and password for managing the claims through their portal. I am not too fond of this model, but if you have something like that, then you can go ahead and use it. Accessing the clearinghouse interface can give you a little bit more accurate information, but ultimately, the information should flow back to your practice management system.

These are the typical services offered by clearinghouses. As a biller, it is of utmost importance that you understand the clearinghouse reports and the clearinghouse processes so that you can help the physicians with the resubmission of claims.

The claims rejected by the clearinghouse are typically on account of missing information. The most common missing information types are –

  • Mismatch of the patient name with the data available with the insurance company
  • Mismatch of the gender (most often either the gender is wrongly mentioned in the claim or not provided)
  • The most common reason for denial is incorrect NPI. Sometimes you are supposed to send a group NPI, but an individual NPI of the physician has been submitted.
  • Sometimes the tax ID is incorrect.

All of these can result in the claim being denied by the adjudication system of the provider. Even as you learn about clearinghouse in detail, it’s important that you understand these fundamental aspects of a clearinghouse. Regardless of the clearinghouse you use or the practice management system you use, these standard procedures are the same across clearinghouses.

With this, I wish you all the best, and I hope that you now have a better understanding of the clearinghouse process and the claim management process. Once you start your medical billing company, this will become part of your daily workflow.

Thank you for watching this video. I would love to hear your feedback on my videos on Instagram and YouTube.