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Understand Clearing Houses

Understand Clearing Houses

Clearing houses affect revenue flow through denials. Understanding them and their processes helps you speed your re-submissions.
After a claim file is sent to the clearinghouse, an edit report is sent back to the practice, indicating claims and charge lines rejected with various edit problems. If the details in these edit reports are not attended to, the claims and charges will never make it to the payer and be processed for payment. Uncorrected, these claims fall into a “black hole” and will remain on the practice’s accounts receivable forever and will exceed the timely filing limits set by the payer. Many practices that do not attend to these edit reports mistakenly think that all of their claims have gone through the clearinghouse and on to the payer. And, keep in mind, edits can be received from the clearinghouse at multiple levels, including the clearinghouse edits, where the clearinghouse scrubs the claims for errors in the submittals and then a second time, when a claim is sent on to the payer and the payer rejects the claim, usually for a beneficiary not on file or an incorrect beneficiary ID number, etc.

Review Clearing House Mail

All of these returned claims MUST be reviewed by the practice, corrected, and resubmitted with the corrections so that the clearinghouse and/or payer accepts the claims for further processing. This means that the practice must make these edit reports top priority and work all of the errors that come through, making sure they are all corrected so the claims can be submitted cleanly and go through the clearinghouse to the payer on to processing. As long as an edit comes back to your practice with any error, no matter how minor it appears, it means that the claim is not getting processed by the payer and will never get processed until corrected and resubmitted.
Some clearinghouse edit reports come back to the practice as paper reports. The practice must open each claim, determine what is wrong and how to correct it, and make the correction and resubmit it to the clearinghouse. Some of the more sophisticated clearinghouses today have the ability to work the edits electronically, in the claim file, on the clearinghouse website. This feature enables the practice to log into the clearinghouse, open the edits on line, determine what is wrong and make the correction to the claim right in the clearinghouse file, live. Then once the corrections are made, the claims are then re-scrubbed and if they have no errors, they move on to the payers. This is much quicker for getting the corrected claims out to the payers. But keep in mind, you need to go back into your practice management system and make the same corrections that you made in the clearinghouse file, in your PM system so that the clearinghouse claims match your PM system claims.

Clearing House Edits

Make sure you do not ignore the clearinghouse edit reports and let them just pile up. Every time a clearinghouse edit is ignored, money is being left on the table and the practice’s accounts receivable is growing, with money that can never be collected since it is timing out of timely filing. This is just one important best practice with claims submission and optimizing payment for your practice.

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Barbara Cobuzzi

About Has 99 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is an independent consultant, CRN Healthcare Solution, Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

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