Health Care Clearinghouses

In recent years, there’s been a growing recognition of the importance of mental and behavioral health care in overall health and well-being. As a result, insurance companies are starting to expand their coverage of mental health and behavioral health services. This shift is a welcome change for many individuals and families who previously struggled to access affordable and comprehensive care for mental health conditions.

Still, behavioral and mental health care providers face unique challenges when it comes to submitting and processing medical claims. The complexity of mental health diagnoses, treatments, and insurance coverage often adds an additional layer of administrative burden, which can lead to billing errors and delays in payment. This is where health care clearinghouses can be a valuable resource. 

A health care clearinghouse is a third-party organization that processes electronic healthcare transactions between providers, payers, and other entities. Its primary function is to standardize and streamline the exchange of health care data, reducing administrative burdens and ensuring compliance with regulations. In this article, we explore the benefits of health care clearinghouses for health and human service providers as well as how to access them.

Reasons for Using a Clearinghouse

Health care clearinghouses have become an essential part of the claims process, providing numerous benefits to providers, payers, and clients, including:

Cost-Efficiency

Clearinghouses offer providers a streamlined way to submit medical claims or eligibility inquiries and receive payments. By reducing administrative tasks, providers can maximize the efficiency of their administrative staff. This leads to significant cost savings in several ways. First, an agency may reduce costs associated with errors more prone to in-house processing. They can also scale their services appropriately with a reduced burden on administrative overhead.

Higher Approval Rates

Another benefit of health care clearinghouses is fewer delays or outright denials on expected payments. In a process called “claims scrubbing,” clearinghouses perform a thorough review of provider submissions, ensuring that all data is accurate, complete, and on the correct forms. Many clearinghouses have electronic flags, revealing issues that may cause a claim to be denied, allowing providers to address these issues before submitting the claim.

Faster Claim Processing

Clearinghouses act as intermediaries between human service providers and payers, facilitating a faster and more efficient claims process. Issues with claims often are communicated through the clearinghouse, which has dedicated staff and time to resolve them quickly without interrupting care. This results in providers receiving payments in a timely manner, improving their cash flow and allowing them to reinvest in their organizations.

Health Care Clearinghouse Functions

Health care clearinghouses play a vital role in the medical claims process, helping to simplify and streamline the process for mental health and behavioral health providers, payers, and clients. Our partners at Change Healthcare offer a variety of functions through their medical network to help providers manage claims more efficiently, including:

• Payer connectivity services: Single transaction entry points enable providers to electronically connect with a wide range of payers. This is helpful when a service requires multi-submission to primary and secondary insurance companies or third-party payers, or when other health care providers need to access human service claims to coordinate care.
• Medical claim attachments: Using attachments allows providers to submit additional documentation along with their claims, such as medical records or test results. This helps to provide a more complete picture of the client’s health status, reducing the chances of claims being denied due to a lack of information.
• Provider credentialing and network management: This protocol helps agencies manage their networks of affiliated providers, ensuring they all meet the necessary credentialing requirements. This helps to improve the quality of care provided to clients and ensure compliance with regulatory requirements when clients receive referrals or managed care.
• Advanced claim management: An additional layer of protection offers human service providers the tools to help manage claims with more detailed oversight. These tools include automated claim status updates and alerts for potential issues, improving transparency and reducing the need for manual follow-up.
• Claims automation and remittance: Submitting and tracking claims electronically practically eliminates the need for paper-based processes, improving efficiency, reducing errors, and making an organization more environmentally friendly. Providers can also receive automated remittance advice, improving transparency and reducing manual follow-up.
• Eligibility and client access: Enjoy real-time eligibility verification and benefit information, allowing providers to quickly determine client coverage before they provide a service. This service enables providers to have a more accurate understanding of a client’s insurance coverage, ensuring they receive the proper care and keeping the client informed to avoid surprise costs.
• Connect Center: This refers to a centralized platform for health and human service providers to manage their claims, remittance, and eligibility information. This improves efficiency and reduces administrative tasks by providing a single platform to manage all claims-related tasks.
• Payer data exchange: This is a platform that provides a secure way for multiple providers and payers to exchange data electronically, such as claims and eligibility information.
• Hosted payer services: Outsourcing the entire claims processing and management to a third-party provider is also an option. This service reduces administrative responsibility even more by offloading the submission of claims to an experienced partner from the beginning of the process.

Who Benefits From a Health Care Clearinghouse?

Health care clearinghouses play a crucial role in the claims process, providing benefits to a variety of stakeholders, including:

• Health care and human service providers: By using a clearinghouse, medical, mental health, developmental disabilities, substance abuse, housing, and other service providers can streamline their administrative processes. This can help reduce errors, save time, and improve the accuracy of data. With features such as electronic claims processing and automated eligibility verification, health care providers can focus more on providing quality care to their clients.
• Clients: Clearinghouses can help to speed up the authorization process, allowing clients to receive care more quickly. They also help resolve billing issues more efficiently, so clients have less worry about navigating complex billing processes or receiving unexpected bills.
• Payers: By using electronic claims processing and other clearinghouse services, payers such as insurance companies can reduce paperwork and costs associated with claims processing. This can result in faster and more accurate claims processing and ensure payers only remit exactly what’s due.

A primary benefit of working with clearinghouses for all stakeholders is to ensure that their applications, services, claims, and client experiences are HIPAA-compliant.

Determining Whether A Clearinghouse Is Right for Your Agency

Mental and behavioral health care providers have a lot to manage, from providing quality care to their clients to managing administrative tasks like submitting medical claims and managing client information. A health care clearinghouse can help alleviate the burden of administrative tasks, allowing providers to focus more on delivering care. But how can a mental or behavioral health care provider determine if they should work with a health care clearinghouse?

As a mental or behavioral health care provider, deciding whether to work with a health care clearinghouse can be a complex decision. To help make this decision, consider the following metrics:

• Standardization: If your agency is already standardized in its approach to billing and administrative processes, and is familiar with electronic data interchange (EDI), then working with a clearinghouse may not be necessary. However, if your agency is looking to standardize and streamline its administrative processes, then a clearinghouse can help to facilitate this.
• Volume: If your agency is handling a high volume of medical claims, a health care clearinghouse can help to automate the processing and submission of these claims, reducing the workload for your staff and minimizing errors in the claims process.
• Service and payment complexity: If your agency deals with complex billing and payment structures, such as insurance claims and authorization requests, a health care clearinghouse can simplify the process by providing automated eligibility verification and authorization, as well as automating payment processing.
• Security management: If your agency is concerned with the security of client data and the handling of sensitive financial information, a health care clearinghouse can provide a secure platform for electronic data interchange and ensure compliance with HIPAA regulations.
• Desire to expand: If your agency is looking to expand its reach and work with a broader range of payers, a health care clearinghouse can provide access to a wider network of payers and help to streamline the administrative process for working with them.

If your agency already has an established system for handling these processes, a clearinghouse may not be necessary. Carefully consider the specific needs and goals of your agency when making this decision.

How To Access a Health Care Clearinghouse

Accessing a health care clearinghouse is an essential step for human service providers who want to streamline their claims management system. The process of accessing a health care clearinghouse may seem daunting at first, but it is actually pretty straightforward and simple. In some cases, clearinghouse services, like those at Foothold Technology, are integrated as a standard component of the EHR ecosystem. Otherwise, the process involves searching for a suitable clearinghouse, selecting the best option, and registering for its services.  Here is more information about each step:

Search and Compare Clearinghouses

The first step in accessing a health care clearinghouse is to search and compare the different options available. With so many clearinghouses available in the market, it can be challenging to select the one that best suits a health care provider’s needs. It’s crucial to compare the features and costs of each clearinghouse option before making a decision. Factors to consider may include the type of medical claims accepted, fees and pricing, integration with other systems, and customer support.

Select a Suitable Company That Meets Your Needs

Once a provider has compared different clearinghouse options, the next step is to select the one that best suits their needs. The selected clearinghouse should be user-friendly and easy to integrate with the service provider’s case management system. It’s important to select a clearinghouse that offers excellent customer support and a reliable claims management process.

Register for a Full Suite of Services or Choose the Ones That Work for You

The final step is to register for the chosen clearinghouse’s services. Health care providers must provide personal information, agree to terms and conditions, ensure HIPAA compliance, and submit a fee. The registration process is simple and straightforward, and the service provider will be able to access the clearinghouse’s services once the registration process is complete.  

What To Look For in a Clearinghouse

• HIPAA Compliance: It is important to ensure that the health care clearinghouse is compliant with HIPAA regulations to protect the confidentiality and security of client data.
• Electronic health records (EHR) compatibility: The clearinghouse should have the capability to integrate with electronic health records systems to streamline the claims process and reduce errors.
• Electronic Health Network Accreditation Commission (EHNAC) Accreditation: Look for a clearinghouse that has been accredited by the EHNAC, which sets industry standards for health care transaction processing and data exchange.
• Claims volume: The clearinghouse should be able to handle the volume of claims that your agency generates on a regular basis to ensure timely processing and reimbursement.
• Service offerings: Evaluate the clearinghouse’s service offerings to determine if they align with your agency’s needs. For example, if you primarily work with Medicaid clients, ensure that the clearinghouse has experience processing Medicaid claims.
• Customer support: Look for a clearinghouse that offers reliable customer support to address any questions or concerns that arise during the claims process.
• Pricing: Clearinghouses may have different pricing structures, such as per-claim fees or monthly subscription fees. Evaluate the costs associated with each option to determine which is most cost-effective for your organization.
• Turnaround time: The clearinghouse should be able to process claims quickly and efficiently, which can help you receive payments more quickly.
• Integration with other systems: Determine if the clearinghouse can integrate with other systems your agency uses, such as your case management software or electronic health records system.
• Security measures: The clearinghouse should have robust security measures in place to protect against data breaches and other security threats.

What You Need To Know

Health care clearinghouses are becoming increasingly popular because of their numerous advantages. From streamlining the claims process, getting complex claims approved, and improving overall efficiency, they provide a multitude of benefits to mental and behavioral health providers, clients, and payers alike. With the right clearinghouse, clients enjoy improved access to care, as human service providers can focus more on client care rather than administrative tasks. Payers also benefit from improved cost savings, as a streamlined claims process leads to reduced administrative costs. Clearinghouses help to create a more efficient and effective health care system, benefiting all those involved in the process.