What Is a Clearinghouse in Medical Billing?

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Article Background

A medical billing clearinghouse is a third-party intermediary that acts between healthcare providers and insurance payers. Its role is to receive claims from providers, review and check them for errors, and then forward clean claims electronically to the appropriate insurers.

Think of a medical billing clearinghouse like a triage nurse for your claims. Just as a triage nurse quickly checks patients to identify and prioritize issues before they see the doctor, a clearinghouse reviews your claims to catch errors and direct them properly before they reach the insurance payer, helping ensure faster and smoother processing.

So, exactly what does a clearinghouse do, and how can this create positive impacts for your organization? Also, what are the key attributes and capabilities to seek in a medical billing clearinghouse vendor? 

What Does a Clearinghouse Do During Claims Submission?

Acting as an intermediary, a medical billing clearinghouse receives and reviews claims generated by the provider, flagging any issues for remediation. The clearinghouse then electronically forwards clean claims to the insurer. (For context, think about how a postal sorter corrects/standardizes mailing addresses and organizes pieces to improve delivery accuracy and reduce postage costs for the sender.)

During claims submission, a clearinghouse performs several key functions that help streamline the revenue cycle:

Standardizing claims format for electronic data interchange (EDI)
Checking for errors, also known as “scrubbing”
Routing claims to the appropriate payers
Updating providers on claim status

Common Problems a Clearinghouse Helps Solve

In a hectic provider billing environment, where staff are often stretched to the limit, errors and omissions are inevitable. The costly consequences include claim denials and payment delays.

The right medical billing clearinghouse can help protect your revenue stream by preventing problems due to formatting errors, missing codes, incorrect patient data, duplicate submissions, and other issues. Additional benefits of partnering with the right clearinghouse include improved tracking and visibility of payer responses and adjudication timelines, as well as easier, more efficient multi-payer workflows.

Choosing the Right Clearinghouse Partner

Be advised that not all medical billing clearinghouse solutions deliver the same results. In fact, choosing the wrong vendor may create billing bottlenecks instead of boosting productivity and revenue. Following are crucial attributes and capabilities to seek in a clearinghouse partner:

Offers clearinghouse tools that integrate with your electronic health record (EHR) and billing systems
Has full compatibility with payer systems
Offers rejection management tools
Provides real-time tracking of claim status
Demonstrates strong regulatory compliance
Delivers comprehensive, prompt customer support

TruBridge offers Medical Claims Clearinghouse solutions that meet and exceed these criteria. 

TruBridge Medical Claims Clearinghouse Solutions

Tailored to rural and community providers, TruBridge Medical Claims Clearinghouse solutions encompass a comprehensive set of services designed to improve billing accuracy and secure the timely payment of every dollar to which your organization is entitled. This set of services, part of TruBridge HFMA Peer Reviewed® Revenue Cycle Management (RCM) solutions, includes: 

Transaction processing – automates the electronic processing of healthcare transactions, such as claims submissions, remittance advice, eligibility verification, claim attachments, and claim status transactions
Data validation and editing – ensures that all healthcare transactions meet industry standards and regulatory requirements, minimizing errors and fully complying with HIPAA and all other healthcare mandates
Claims status checking – tracks the status of claims in real time, allowing you to monitor their progress throughout the reimbursement process
Reporting tools and analytics – provide insights into your RCM performance, such as claim acceptance rates, denials, and other key performance indicators

In summary, TruBridge Medical Claims Clearinghouse solutions don’t just represent an  intermediary step in your billing process. They support a healthier revenue stream by minimizing errors and ensuring the submission of consistently clean claims. This, in turn, reduces payer rejections, along with the need for costly appeals, reworks, and resubmissions, and ultimately helps drive faster reimbursements.