Clearing Houses

Healthcare clearing houses are the jugular of the US healthcare system. They facilitate the most important part of the Revenue Cycle Management (RCM) cycle – submission and tracking of claims to the payers. They work as intermediaries between the providers and payers by creating channels that allow providers to reach the payer systems without the overhead of point to point connections. As is the case with any other industry, with time, competition has caused players in this fierce market to extend services that were not envisioned during their inception. Currently following are a few services that most of the clearing houses out there provide:

Typical services offered by a Clearing House:

Challenges
  • Eligibility checking within the PMS system – batch as well as RTE
  • Claim validation within the billing system as opposed to getting claim edits at the clearing house system. This impacts RCM efficiency.
  • Inability to deliver payments.  While most clearing houses today offer a way for patients to make payments to the providers, the same capability does not exist for payer payments.
  • Balancing the consolidated ERA received. As the 835 files often have information relating to multiple patients, encounters, Claims and line items, matching of a payment against the amount owed is a difficult task for physicians. If automated, this can save a lot of time of the end users.
  • Maintenance of legacy systems. Many clearing houses setup their systems over one or two decades back. With time, the business logic grew so complicated that the clearinghouses figured it was best to continue with those. Now, as those technologies become obsolete, their maintenance has become overwhelming while limiting the capabilities they can offer to end users.
  • With acquisitions, the IT landscapes of these organizations have disparate systems that are making them bleed. There is an opportunity and a need to consolidate these systems through technology migrations. But as most of these lack proper documentation and will need experts who understand technology and business, they continue to function in a sub-optimal way.
Regulations and recent trends

HIPAA 5010

Adoption of standards that covered entities must use during electronic transactions, such as claims, remittance, eligibility, and claims status requests and responses. Migration from X12 Version 4010A1 to 5010 and from NCPDP 5.1 to D.0 happened as part of this.

CAQH CORE

Adoption of standards that covered entities must use during electronic transactions, such as claims, remittance, eligibility, and claims status requests and responses. Migration from X12 Version 4010A1 to 5010 and from NCPDP 5.1 to D.0 happened as part of this.

PCI

With the patient responsibility portion of healthcare expenses increasing, more and more patients are forced to cover their medical expenses through their credit cards. As these organizations deal with the card information they expose them to security risks. Therefore, PCI compliance is becoming increasingly important in the US healthcare.

How can we help you?

We can help you engineer your end to end system spanning the entire RCM cycle. With the competition forcing innovations that appeal your customers, we understand that there is always a roadmap you are chasing. We can work in tandem with you to translate your vision into a solution faster and cheaper leveraging our global teams.

We understand your world and the regulations that affect you. We make your life easier by deciphering the compliance requirements, translating them to system requirements and implementing those for you.

We help you do a technology refresh of your systems to help you gain competitive edge. Not only do we help you embrace modern technologies, we also support your legacy applications for as long as you want them to survive.

We understand that your end users today are stormed with more data than they can manage. Given the pressures of cost, time and regulations they do not have the time or the patience to sieve through this data. We help you present this to them in a way that makes sense to them, addressing only what requires their attention. We have the necessary tool-set and the depth of domain to equip you better to deliver meaningful insights to your customers.

With consumers spending their time on mobile devices more than ever, any and all interactions that CAN happen over a mobile platform WILL happen over those. We help you extend your desktop applications to mobile platforms to make them available to your users even when they aren’t at their desktops.

We understand your environment and help you focus on what is core to you. With our systems and processes in place, we are positioned to maintain your application portfolio in a consistent and predictable manner.