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Medical Billing Clearinghouse: Are You Ready to Handle a Medical Malpractice Claim?

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Medical malpractice claims have become so common that 42% of physicians will face one at some point in their career according to the American Medical Association. The process of investigating, processing claims and responding to legal requests can be quite complex and time consuming for you and your clinic.

The legal process itself can take up to five years, but there are several ways to prepare your staff. First, medical records and treatment notes must be thorough. Memories years after the treatment can be sketchy. You’ll want to be prepared to provide a detailed account of the patient’s medical case, the treatment, and all communication with the patient.

The physician will be required to respond to a series of questions during the legal process. Accurate and complete information about the patient’s medical case and claims processing decisions made must be available. During deposition meetings and court testimony, the doctor will be required to answer questions from attorneys for several hours under oath.

Your medical claims software must be capable of storing accurate and detailed patient records. You will want your staff to be able to retrieve information quickly during an investigation. You will also want to feel confident that all medical claims have been processed perfectly.
When you are faced with a malpractice claim there is not much you can do to speed up the process of responding. However, the Apex EDI software will make the burden a little easier for you. With accurate information at your fingertips, there is a good chance your malpractice claim could be withdrawn or dismissed early.

Contact us today to request a free software demonstration.

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Medical Billing Clearinghouse: How to Settle Medical Billing Disputes

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Health care insurance billing is very complex and can be quite confusing. At some point in time you will no doubt find yourself in a billing dispute trying to determine what has been paid for and what payment is due. It’s important to know how to dispute a medical billing issue, how to appeal a denial and to be able to strengthen your case for receiving payment.

The best prevention is a little preparation up front. Make sure you keep a record of all communications you have about the patient’s healthcare. You will want to note phone calls made with the date and time of the call, the number you called, the people you spoke with, and exactly what you discussed. Also save copies of emails or written communications.

You will also want to have a copy of the insurance plan’s Summary Plan Description (SPD) on hand for reference. This document clarifies all billing services covered by insurance. You will also find a list of any exclusions in it. If you have questions about the policy, you can use the SPD to find the answer.

When there are billing discrepancies, you will want to be certain first that the health care provider billed the correct insurance plan. Simple errors in name, policy number, or address can result in rejected claims. It’s important to understand your plan’s annual deductible, the different terms and limits set forth in the plan for the medical services.

Also check for errors and make sure all charges were applied correctly to the insurance provider. You will want to make sure that there aren’t multiple bills being sent for the same service. If a payment was delayed, it’s not uncommon for a patient to receive a follow up notice for the same service although they may have already submitted the payment.

If a claim has been rejected or denied, find out the specific reasons why. When a patient disagrees with the reasons, they may file an appeal with the insurance company. It’s important to take this action quickly and provide any documentation supporting the patient’s position.

While we are certain you will be faced with questions about medical billing and insurance coverage, we can simplify the record keeping process and minimize errors for you with our electronic billing software.

Contact Apex EDI to request a demonstration of our software today.

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Medical Billing Clearinghouse: What is the Role of a Medical Clearinghouse?

In the world of medical billing, there are a few concepts that can get a bit confusing. One of these concepts is that of a medical clearinghouse. What exactly does a clearinghouse do, and why is it important?  Let’s discuss the role of the medical clearinghouse, its benefits, and how to choose one.


What They Do

A medical claims clearinghouse acts as a middleman between the provider (doctor, dentist, chiropractor, etc.) and the payer (insurance company). The practice management software on a billing professional’s computer creates an electronic file (the claim) also known as the ANSI-X12 837 file. This file is then uploaded to your medical billing clearinghouse account.

From here, the clearinghouse then checks the claim for errors, ensuring that the claim can be properly submitted to the payer. Once the claim passes inspection, the clearinghouse securely transmits the electronic claim to the payer with which it has already established a secure connection that meets the strict standards laid down by a HIPAA.  The claim is then either approved or denied by the payer, in which an approved claim generates a payment of services to the provider, and a denied claim may require additional information to procure processing.

Benefits of Clearinghouses

The main benefit of the clearinghouse is efficiency. Clearinghouses scrub medical claims to ensure correct data entry for properly processed claims. Without this error checking, incorrect claims would be submitted to payers on a more regular basis. Incorrect claims cause inefficiency in the workplace, more work for your staff and the payer, and often result in denied claims due to incorrect filing or coding.

Another benefit of using a clearinghouse is the integration between the payer’s software and the provider’s software. Each payer and provider are likely to use different softwares, but these softwares are not necessarily compatible with each other. When using a clearinghouse that integrates with each software separately, the payer and provider are able to allow each software system to communicate through electronic data integration (EDI).

How To Choose One

When choosing a clearinghouse, it is important to keep the following aspects in mind:

  • User-friendly Interface
  • Integration with Existing Practice Management Software
  • Customer Service & Support
  • Privacy Practices & Compliance

With a friendly user interface that integrates with dozens of existing practice management softwares, Apex EDI is the premier choice for medical claims processing. Our clearinghouse is dedicated to upholding exceptional practices with regards to customer service, as well as compliance with federal privacy practices such as HIPPA.

For more information, be sure to reach out to us on our Contact Us page.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

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Medical Billing Clearinghouse: Top Reasons to Use A Medical Billing Company – Cost Savings and Consistency

As a healthcare provider, you wear a lot of hats. Medical billing might be one of them. Let’s discuss why it will be beneficial for your healthcare practice to consider outsourcing billing practices to a professional medical billing company.041019-N-5821P-019

Cost Savings

The cost savings associated with using a medical billing company as opposed to completing billing in house is significant. A study completed by Physician’s New found that the typical cost to process medical billing procedures in house is approximately $118,000 per year. The cost of billing department costs per year when the practice of medical billing is outsourced? $4,000.

That’s less than 1/30 of what your healthcare practice would pay if you continued to process medical billing in house. In addition to significant billing department costs, your practice will also be able to collect up to 5-15% more of billings processed. While that might not seem like much now, it can add up into a significant profit over the course of a fiscal year.


Another reason to use a medical billing company is the consistency you will experience. Consistency in the form of denied claims appeals, staffing requirements, and various other processing practices for medical claims and billing procedures.

The professionals who are employed by the medical billing company you choose to outsource your billing procedures to are experts in their field. They know exactly what needs to be completed in order to process claims quickly and efficiently. Not only will they be able to uphold industry standards, the medical billing company will be able to efficiently adhere to changing standards and legislation in the field.

Apex EDI is a great method of streamlining your process with medical billing. In order to ensure that medical claims are billed properly and efficiently, consider utilizing the software integration behind Apex EDI. Apex OneTouch, the desktop app, integrates seamlessly with over 30 practice management softwares to ensure fast, efficient, and accurate billing for you and your medical billing provider.

For more information, visit our products page.

Articles with this disclaimer may not represent the beliefs or core values of Apex EDI. The following is simply a summary taken from the industry’s general community to help readers stay up-to-date on what people are talking about. 

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Medical Billing Clearinghouse: Understanding Medicare’s Role – Five Questions Medical Billing Companies Need to Know.

Understanding Medicare’s Role in Advance Care Planning.

As a follow-up to our recent article on the 2016 Medicare regulation change that allows physicians to bill for advance care discussions, we thought we’d share a few pertinent details on what “advance care” really means. Though doctors have some leeway to cover what they think is best, the more medical billing companies know, the better they can protect their clients.

Everything from updating patient management software to health insurance claims processing can be affected by the change – here’s a primer on advanced care terms and technicalities.

As a Matter of Fact…

  • ¾ of the 2.5 million Americans who pass away each year are 65 and older.
  • Medicare is the largest health insurance provider for Americans in their last year of life.
  • ¼ of all Medicare health care coverage is spent on beneficiaries in their last 12 months of life.
  • 90 percent of aging adults report that they’d prefer to die at home, though historically only 1/3 actually do.

What is “end-of-life care” exactly?

In simple terms, end-of-life care includes all the services provided for patients in the days (or even years) prior to their death. Medicare covers a comprehensive list of end-of-life health care services, including hospital stays, diagnostic testing, physician visits, home health care, prescriptions, and so forth. Though a patient’s prognosis may be “terminal”, end-of-life services can be intended to either cure conditions or simply provide symptom relief.

What does “advance care planning” entail?

The goal of advance care planning is to help patients and their family members/caregivers better understand all the care options available for them at the end of their lives. Typically, physicians will discuss the various options available (curative treatments, pain management options, at-home care or in-hospital stays for example), make recommendations on a treatment plan, then help the patient to determine which options best align with their individual desires. (In terms of billing for claims processing software, there are two codes to cover these conversations. The first covers the first 30 minutes of discussion – which may be all a patient needs. There is an additional code that covers additional 30 minute conversations as necessary.)

Are physicians the only Medicare-approved resources for advance care discussions?

No. Under the new regulation, Medicare covers advance care planning discussions provided by physicians and other health professionals, such as nurse practitioners, who bill Medicare according to the official physician fee schedule. Discussions should take place in medical offices and approved facilities and hospitals, and can be part of an annual check-ups or wellness visit. (Note for health insurance claims processing: Medicare should be billed separately for advance care.)

What are “advance directives” and in terms of patient management software, are facilities required to keep records of them?

In essence, advance directives are written instructions that define a patient’s wishes for end-of-life care. They become invaluable in instances where a patient is incapacitated or is no longer able to speak for themselves. They are often referred to as a “living will” and typically result from advance care planning discussions. Advance directives define specifically the medical treatments and types of treatments each patient prefers as they are nearing dying.

Advance directives fall under state regulations. Official forms for directives vary from state to state as do the requirements for documentation. Though patients are not required to have one, the Patient Self-Determination Act of 1991 requires that hospitals, skilled nursing facilities, etc. ask each patient if they have an advance directive at the time of admission.

What is “palliative care” and is it covered by Medicare?

As opposed to services intended to cure or treat a specific illness, palliative care generally focuses on managing symptoms and providing comfort to patients nearing the end of life. (Although palliative care is most common for patients receiving end-of-life care, it is not restricted to those with terminal illnesses. It’s also very common for people living with serious chronic illnesses including cancer, heart disease and depression.) In terms of health insurance claims processing, Medicare beneficiaries can claim coverage for palliative care services whether they are offered in combination with curative treatments or not.

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