Electronic data interchange (EDI) enrollment is the “check engine light” of provider data management and enrollments. When that light comes on, it’s easy to dismiss it as a minor nuisance, but often it signals a serious, underlying problem to be fixed.

Clearinghouses are the entities largely responsible for carrying out EDI enrollments and other administrative tasks, acting as the liaisons and gatekeepers between providers and payers. Yet, even clearinghouses can get caught in the bureaucracy that surrounds much of healthcare administration and skip important, routine maintenance tasks.

When a healthcare provider is choosing a clearinghouse, it’s critical to carefully evaluate each entity and pick the best fit for their current and future needs. The provider should ask the clearinghouse a few key questions. If the clearinghouse can’t answer these, well, the check engine light might already be on.

How many mergers and acquisitions has the clearinghouse gone through?

Clearinghouses are no different than the rest of healthcare — mergers and acquisitions are common and frequent. And just like hospitals and other clinical mergers give rise to many administrative tasks, the same occurs with clearinghouses.

Each clearinghouse has its own way of storing provider data, managing tasks, checking statuses with payers, and other processes. Additionally, each clearinghouse has its different payer connections. This array of differences means major changes take place during mergers and acquisitions, and these events introduce a lot of duplicity into the organization. Some additional follow-up questions could be: What was the reason for the acquisition? What were the goals of the acquisition? Were the goals accomplished and how? Did you reduce staff? Have the challenges of duplicity been resolved? If so, how?

Although, once the work is done, the outcome is usually a more efficient and unified entity. Evaluate if the amalgamations resulted in a stronger, better clearinghouse, or just a bigger clearinghouse.

How well aligned are the clearinghouse’s growth strategies with yours?

Related to mergers and acquisitions, it’s critical to inquire about a clearinghouse’s overall growth strategies in the short and long term. A clear roadmap of their business and investments will provide insight into the organization, and if its plans fit with yours. Not only should you be concerned about its future growth, but if they will be able to meet the demands of your growing and evolving practice.

Proceed with caution if a clearinghouse has recently gone through a merger or acquisition, has gone through multiple, or is currently going through one. These situations don’t necessarily raise red flags, but they may indicate a need for better understanding of how one of these situations will affect the current relationships with clients.

How many payer connections does the clearinghouse have?

“The more connections the better,” rings true in most cases, including how many payers a clearinghouse is connected to. Each year, 15 billion transactions occur between more than 900 payers and nearly 900,000 healthcare providers. It’s simple — the more payer connections, the simpler the process.

In addition to how many current payer connections, providers should also find out about the rate at which the clearinghouse is adding new payers. If they aren’t actively growing their network, they are doing a disservice to their clients.

Another important factor to consider is turnaround time. When a clearinghouse is already connected to a payer, the process will be faster than if they need to jump through hoops (e.g. go through another clearinghouse) to complete a task. For a payer enrollment (credentialing with payers), turnaround times can range from weeks to months. During this time, providers cannot receive reimbursements from these payers. And with the average provider seeing 20 patients a day, those missed payments add up quickly.

More efficient turnaround times can be achieved through direct payer connections, which brings us to the next question.

How many direct payer connections does the clearinghouse have?

While lots of connections is a good start, it holds up here that quality has an edge over quantity. For example, an airline can get you from Chicago to Los Angeles. But, is it a direct flight, or do you have a three-hour layover in Dallas? Each stop and diversion costs time and impacts productivity. Similar to air travel, a direct connection in clearinghouses is preferred.

Through direct payer connections, partners and clearinghouses can transact with payers one-to-one, without added layers. While it does require some work and thought, it ultimately delivers an ROI to partners and the providers they work with. If you want to dig deeper, ask them how many direct connections they have with your top 10 payers.

What data do you have to support your claim of superior customer service? 

Most businesses that offer a product or service usually boast about their “first-class” customer service, and clearinghouse are no different. However, clearinghouses are notorious for being difficult to get a hold of and long wait times to talk to a representative.

Beyond what they claim, ask for quantitative data that backs it up. A few specific examples: How is your superior service measured? What metrics do you use? What are support call volumes? Where is your call center located? How is the call center staffed? What are your turnover rates? The answers, or lack thereof, should help reveal the support experience you can expect.

Like with other criteria for finding a clearinghouse, it’s most important to pick one with a level of customer support that meets your organization’s unique needs. Ask them to include a commitment to customer support in the contract; if they push back on this, it might be a sign to go in another direction.

Quick tip: Try contacting their support team as a test. This may disclose wait times, who is answering the phone, if you get rerouted, and how they treat customers. See how the conversation goes and the feeling you get from the interaction. Hopefully, you’re pleasantly surprised.

Once all of these questions are answered, you should be able to make an informed decision. Remember, the clearinghouse should make your life easier, not create additional stress. When there’s a good match between a practice and a clearinghouse, it’s a positive experience with increased productivity.

If you need help sorting through these and other questions for your clearinghouse, contact us. >

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