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Claims Clearinghouse: Medical Claims Clearinghouse

With all the regulation changes that have happened and have yet to happen, navigating the healthcare revenue cycle can be overwhelming. So much of what physicians do is overseen by one regulatory committee or another. In fact, often it is multiple committees that oversee one aspect of healthcare. Understanding what the healthcare professional needs to comply with can be costly. That is why having a medical claims clearinghouse on your side is a powerful partnership that no healthcare practice should be without.

In 2010 congress passed the Affordable Care Act (ACA). This law put into place numerous regulation changes. Some of those changes were obvious, like increased patients with insurance, others were not so obvious, such as insurance companies providing administrative and financial transactions that are compliant with the standards set forth. A medical claims clearinghouse is there to help manage these changes on behalf of the physician. They can help physicians by cutting through overwhelming documentation and let them know what they need to act on. They also maintain the relationship with the insurance company when it comes to the electronic interchange of data. This allows the medical claims clearinghouse to advocate for the provider when it comes to establishing connections for the administrative and financial transactions the insurance companies are now required to provide physicians. These transactions include, but are not limited to, electronic eligibility and benefit verification and electronic explanation of benefits (EOB’s).

With the ACA a number of regulatory bodies became prominent in the healthcare industry. One of those bodies is the CAQH body. They are responsible for the CORE operating rules. CORE operating rules are mandated operating rules in section 1104 of the ACA. The purpose of these operating rules is to:

  1. Promote quality interactions between health plans, providers and any of their intermediaries.
  2. Reduce costs and frustrations with healthcare administration for providers and others.
  3. Facilitate administrative healthcare information exchange, this is where a claim medical clearinghouse acts as the providers representative in corresponding and partnering with insurance companies to insure the timeliness of an exchange of the information the provider needs to streamline their revenue flow.
  4. Encourage administrative and clinical data integration. Here is another instance when a medical claims clearinghouse is a help to the provider. Medical claims clearinghouses can partner with practice management software to create a more seamless revenue management cycle, saving time and money on the providers end by making the revenue cycle more efficient.

The medical claims clearinghouse can also provide an extra plus in service by making sure that electronic data is submitted in the most current regulated format. In January of 2012 there was a regulation change that required the format of electronic data be transmitted in the ANSI 5010 format rather than the ANSI 4010 format. A partnership with a medical claims clearinghouse allowed providers to continue sending their data in whatever format they could while the clearinghouse would convert it to the correct format for submission to the insurance company. This service could provide money savings to operating costs as well as extra level of convenience to daily operations.

Another way the medical claims clearinghouse helps physicians is by validating data on their claims. This year that is particularly important because of the upcoming ICD-10 transition. While the ICD-10 transition will mostly effect physicians through the practice management software and insurance companies medical claims clearinghouses will be assisting physicians by testing claim filing with insurance companies as well as testing with practice management software. This is done so that claims will process as smoothly as possible on the go-live-date of October 1, 2015 so that healthcare professionals can keep focusing on healing their patients.

While providers can become overwhelmed with the over regulation of the healthcare industry there is a friend for them out there. The Apex EDI medical claims clearinghouse is here to help establish the essential connections with insurance companies, facilitate essential electronic data interchanges (EDI) to keep a physician’s business growing, they also provide support and guidance through the ever changing regulation jungle, and they are here to be an advocate for the healthcare professionals that work endlessly to ensure patients get the full coverage of their healthcare plans.

Posted in: Claims Clearinghouse

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