By Crystal Ewing, Manager of Data Integrity, ZirMed
Twitter: @zirmed
As the rules and requirements around health insurance continue to increase in complexity, and financial pressures intensify due to the transition from fee-for-service to value-based billing, more healthcare providers are beginning to look to clearinghouses to help them improve revenue cycle management (RCM) overall.
What they are finding, however, is the decision to use a clearinghouse is more complex than it first appeared. Because once they’ve opted to select a new clearinghouse or expand the list of clearinghouses they work with, they’re faced with another dilemma: do they go with a “best of breed” specialty clearinghouse or choose to work with a single partner that offers an end-to-end RCM solution?
Each has its advantages and can be the right option in different situations. The key is recognizing where in the revenue cycle you need help – and the type of help you need. Taken together, those two factors will point you in the right direction and help you identify the right questions to ask potential vendors.
Start with the problem(s)
While it may be tempting to start building a list of options right away – especially if the organization’s needs are urgent – it’s critical to first do a little soul-searching to determine why there is a need to make a change. You need to understand the problem(s) you’re trying to solve before looking into solutions.
Look at what is working with your current approach versus what is not. Be sure to examine not just the individual components but also how they interact with one another. Think of a symphony orchestra where each musician is playing the right parts, but not at the same time. The individual performances are fine, but taken as a whole they’re more noise than music.
As part of this assessment, you should perform a gap analysis to identify the improvements you would like to make and determine whether they are technical, operational, or some other part of the RCM process. Understanding where your pain-points are, and how many of them you have, simplifies the process of deciding between individual specialty solutions versus an end-to-end solution.
Where a specialty solution will work
There are a couple of areas where using a specialty clearinghouse makes sense. If your organization is limited to a certain type of claim, such as those found in an ambulatory or radiology clinic, a clearinghouse that is specifically focused on that area will be able to help you navigate the revenue cycle very effectively.
Another area where specialty clearinghouses offer good solutions is when you only have one or maybe two areas in your RCM process that need to be shored up. For example, if your evaluation shows you’re doing well in all areas except denial management, and you want to keep the rest of the RCM process in-house, partnering with a clearinghouse that specializes in denial management enables you to make the improvements you need to impact the revenue cycle positively.
As you make your evaluations, however, you should also look at your long-term trends. Denial management may be your only area of concern today. But are other areas headed toward their own challenges, and do you think you’ll be able to solve them internally? If the answers are yes and no, you may want to consider a vendor with an end-to-end solution so you don’t end up making one set of changes now and then have to go through an entirely new change-management process in a few months or years.
Advantages of an end-to-end clearinghouse
Working with an end-to-end clearinghouse is much like bringing your car to the auto dealer for repairs instead of individual shops for brakes and mufflers, engine repairs, transmission work, etc. They can do everything for you, and they have a complete understanding of how changes in one area will affect another.
It starts with the workflow. Rather than logging into multiple systems to look at each piece of the revenue cycle, an end-to-end solution enables you to see all of the organization’s key performance indicators (KPIs) in one place. You also gain a more holistic view of the revenue cycle, making it easier to spot the actual cause of issues rather than the symptoms.
For example, suppose your KPIs show a rise in eligibility-related denials. With individual clearinghouses you would need to move from the claims denials system into other systems to track down the root cause. Once it’s discovered, it may be difficult to remediate in a timely manner.
With an end-to-end clearinghouse, however, you can move around within one system and quickly determine that some or all of your providers are not running eligibility checks before or at the time they’re seeing patients, which is what is leading to the denials. From there you can form a plan to educate your providers, or even build alerts into the electronic health records (EHR) that prompt them to check eligibility.
Another advantage of using an end-to-end clearinghouse is you have a single vendor to go to if there is a problem. There is often a great deal of finger-pointing with individual solutions as each vendor says the problem is not with them. At some level, it doesn’t even matter which vendor is responsible as long as the problem is fixed as quickly as possible. That’s the most frustrating part about the finger-pointing: it delays resolution.
When you have an end-to-end solution, one vendor is responsible for the entire process. They not only don’t waste time assigning blame – they also have the 50,000-foot view of how the entire system works, making it easier to get to the root cause. Which brings us to…
Keep customer support in mind
When providers are considering working with a clearinghouse partner, the focus tends to be on the technical impact it will have on the organization, and metrics such as clean claim rates. Those areas are important—but what sometimes gets ignored in the face of technical metrics is the level of customer support that the clearinghouse provides.
In addition to sharp, prompt technical support, a good clearinghouse partner will be there with you when there’s an issue—they’ll be proactive advocates on your behalf. For example, rather than telling you to call the payer when a claim has been denied, a good clearinghouse partner will either make the call for you or will be on the call with you to help ensure the matter is settled quickly.
In the end it isn’t just about processing data. It’s about doing whatever is required to help you get reimbursed faster, more fully, and 100% accurately.
Know what you need
Both specialty and end-to-end clearinghouses have their place and their value – the key is understanding what your needs are so you can make the right choice.
If your needs are very specific, and contained, a specialty clearinghouse may be the right solution. Otherwise, an end-to-end solution is likely to be the better fit. Especially if you plan to grow or expand your capabilities in the future.
This article was originally published on ZirMed and is republished here with permission.