— Clearinghouse Questions of the Month —
Q— I would like to know if there are clearing houses that specialize in home health claims, and if so, what their rankings are. We are having extensive troubles getting claims paid. We use a billing service, but we have significant delays in payment.
A— Most clearinghouses will handle home health claims. But depending on whom the payer is, getting paid may be a different matter as every payer has their own rules to comply to. As for rankings, reach out to any of our most highly rated clearinghouses and you should be very pleased with the results.
Q— Do the clearinghouse in anyway handle insurance payments, the actual money, or just the billing/claims
A— Clearinghouses do not handle money, they just transmit claims and report. Claim payments can only be made to one of three parties: The patient. The practitioner. Or a billing service. Clearinghouses cannot receive payments unless they are also a billing service, which only one or two of them are.
Q— Interested in determining what is required to become a “payer” for a medical claims clearinghouse. Can you direct me to how this can be accomplished?
A— There are various types of “payers” the most common of which are a health benefit/insurance companies. But there are also TPA’s or Third Party Administrators that adjudicate claims on behalf of payers. For instance
Providence handles payments for insurance companies and Medicare in certain parts of the country. In general these are very large companies. But there are some smaller ones too.
Q— Of our billing, over half of our patients are Medicare or Medicaid. A large percent of the remaining PT’s are bluecrossblueshield. So can you offer an opinion as to which clearinghouse best supports a practice with this billing profile? Also, we need a clearinghouse that verifies eligibility. Don’t all clearinghouses perform that function?
A— Any of our “highly recommended” clearinghouses should work well for you.
Q— A problem our practice experiences is Eligibility Checking for Patients done in real-time. Sometimes we have up to 12 browser windows open all day to check the eligibility. From your website, I learned that this process can be streamlined using a Clearinghouse service.
A— You DEFINITELY would benefit from subscribing to a clearinghouse––one that provides eligibility verification of benefits. Contact any of our “highly recommended” clearinghouses ASAP.
Q— Is it possible for a physician to enroll with more than one clearinghouse at a time?
A— Yes. And with no ill effect. Medicare will allow you to be active with up to 5 clearinghouses at once.
Q— I submit approximately 30 claims a week. i would like to know your pricing. If you have a monthly charge, please tell me what it is. If you charge per claim, I would like to know that fee.
A— For pricing, contact any of our “highly recommended” clearinghouses and ask for a ultra-low volume account, which should play out to about $35 per month.
 
Q— I am desperately in need of a new way of submitting claims, since neither my current practice management software program nor my old billing software program are compliant with the new 1500 forms.What I’d like to know is what are the best options for a sole practitioner, who submits less than 50 claims a month, mostly to commercial insurers but also to Medicare. Also, I use a Mac and need a website-based claims submission. I think I’d prefer being able to just enter the claims data directly into a form on a website, rather than have to purchase or download another software program. Any suggestions?
A— A google search for “medical billing software for MAC” returns these results. One of the software companies listed here offers a free account to print 25 paper claims per month at no cost (free) on the new ICD-10 claim form.
Q— Is it even financially worth it to go through a Clearinghouse when we only have a few (3 at the moment) clients to have to bill. I am sure we will eventually have more but for the learning process of how it all works….I am wondering if it is better to mail in claims until we have learned the process a bit.
A— If the claim amount is small, then yes, I agree, stick with paper until your volume merits spending $35/mo. on a ultra-low volume account.
Q— Is there a uniform way that clearinghouses accept provider submissions? Is each house unique?
A— Electronically: The industry standard format accepted by all US clearinghouses is version 5010 of the
ANSI X-12 837. Otherwise known as the CMS-1500 form. This form can be sent to most clearinghouses either on paper or as electronic data. Electronic data requires a secure (encrypted) connection to the clearinghouse in order to maintain HIPAA complaince. Medical claim transactions are also known as hipaa-tranactions for this reason. For instance, sending medical claim information via a standard email account would be a serious violation of HIPAA law.
