Medical Electronic Billing - Thru a Clearinghouse or Going Direct

Most people think that the only choice is whether to bill on paper, or submit your claims electronically. Actually, if you decide to file your claims electronically, that just opens the door to many other decisions that must be made.

First of all, is your software capable of electronic filing? If you are not sure you will need to check with your software vendor to find out. Most likely if your software is capable of handling the NPI number then it is capable of electronic filing.

Once you determine that your software is capable you will need to decide if you are going to use a clearinghouse. A clearinghouse takes all of your electronic claims and reroutes them to the correct insurance carriers. All electronic claims would be batched together into one file and then uploaded to the clearinghouse. Then you would receive reports from the clearinghouse on the status of all the claims you uploaded.

This method has its advantages since you don't have to separate the claims, you just batch them all together and submit them in one file. The clearinghouse usually charges a per claim fee around $0.39 per claim. If you do a high volume of claims, this can get quite costly.

Most clearinghouses will also drop any claims that cannot be submitted electronically to paper and mail them for you. Some offices like this method because they can just batch ALL claims and send them to the clearinghouse and be done with it. There is no printing, stuffing in envelopes and mailing. Usually the drop to paper charge is a little higher than the per claim fee for electronics.

Another method of medical electronic billing is to file them directly to the insurance carrier yourself. You will need special software for this in addition to your practice management system, but basically you will be acting as your own clearinghouse. The software needed can be costly, but you are eliminating the per claim fee. If you submit a high volume of claims the cost may be worth it. As a billing service billing for over 50 providers across the US, this option works well for us.

We are set up direct with our biggest carriers, Medicare, Excellus, Medicaid and a couple others. Then the remainder of claims go thru a company that acts as a clearinghouse. Submitting direct to the insurance carriers can cut up to 3 days off the processing time.

So once you determine that you want to submit your claims electronically, you need to determine which method will be best for your office. Make sure you research all your options. Good Luck!

Michele Redmond and her mother / partner Alice Scott are co-owners of a medical billing service. They offer an informational website for both physician's offices, billing services, and the general public looking for information or help with their problems with medical insurance billing. Check out their website for more information, more about important changes now going on in Medical Insurance Billing, or to sign up for their free monthly newsletter.