Clearinghouse vs. RCM: Here's the Big Difference

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Searching for a revenue cycle management (RCM) partner and medical claim clearinghouse to manage coding, billing, claims submission, accounts receivable, denied and rejected claims, and collections for your eye care practice? Not sure what the difference is between a clearinghouse and RCM?

Perhaps the most important distinction is that RCM does not replace a clearinghouse, they work together. While many clearinghouses offer RCM services, there are significant differences you may not be aware of before you sign on the dotted line.

Let’s take a look at common questions and answers, and why it’s critical to invest in both for a healthy return on your investment.

What is a Clearinghouse in Ophthalmology and Optometric Billing?

A clearinghouse is an intermediary or middleman (a sender and receiver) that regularly transmits secure, HIPAA-compliant electronic medical claims and financial information from eye care providers to single or multi payers in batch transactions. Payers include Medicare, Medicaid, Managed Care, private insurances, and other third-party payers.

The clearinghouse takes the e-claims you create within your practice management billing software and verifies the claims are complete and comply with payer billing requirements. The clearinghouse then converts the claims to compliant electronic transactions and sends them electronically to insurance payers using Electronic Data Interchange (EDI).

Why Use a Clearinghouse?

Using a clearinghouse expedites reimbursements, reduces errors, and increases revenue by consolidating electronic claim submissions. A clearinghouse gives medical billers and billing managers access to thousands of insurance payers, across different states, from a single location.

The average error rate for paper medical claims is 28%, whereas a good clearinghouse reduces that rate to 2-3%, reports ClearingHouses.org.

If you want to speed up the process even more, choose a clearinghouse that integrates with your eye care practice management software so you can easily manage patient and insurance billing with built-in edit checks.

What is Revenue Cycle Management (RCM) in Optometry and Ophthalmology?

A complete RCM is a financial process that manages claims processing, payment, and revenue generation. RCM and optometric billing services work with your medical billing clearinghouses to streamline and simplify administrative and clinical functions so you can capture, manage, and collect patient service revenue. In other words, RCM keeps your practice moving toward growth, rather than falling behind.

The financial health of any eye care practice depends on an efficient end-to-end revenue cycle management process that works side-by-side with your clearinghouse. Every practice needs a steady stream of revenue to remain in business.

At Fast Pay Health, we specialize in optometry and ophthalmology focused RCM; whereas, clearinghouses offer broad support for many different specialties. Our optometric billing consultants track all claims we submit electronically through clearinghouses and ensure that insurance payers accept the claims. If we notice a rejection, we promptly and manually fix the errors to ensure timely insurance receivables.

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Why Use Revenue Cycle Management?

Keeping up with evolving optometry and ophthalmology billing rules and insurance payer regulations, complicated EDI processes, and monitoring and acting on denied and rejected claims is time consuming and eats away at your cash flow.

When you’re continually managing claim denials and rejections, eligibility and benefit verifications, claims submission, payment posting, AR cleanup, and collections, billing issues start to compound and you find yourself buried under a pile of paperwork.

On average, healthcare providers will see a 5–10% increase in net collections when they outsource their RCM. There are many advantages when you outsource your optometric billing.

Related: How Collaborative Optometry Billing Improves Your Bottom Line

Related: How Efficient Optometry Billing Eased Stress for a Busy Practice

Listed below are critical RCM solutions that help you get paid faster, increase revenue, and improve staff productivity.

  • Eligibility and Benefits Verification: Verifying a patient’s insurance eligibility and benefits is a critical first step before you submit a claim to a clearinghouse. It’s important to ensure insurance data is correct by verifying plan coverage and the amount a patient may owe (e.g., co-pays, co-insurance and deductibles).

  • Provider Credentialing: RCM services simplify the credentialing process by reviewing documentation to determine the provider’s participation status in the health plan, then submits and tracks provider credentialing applications based on insurance plan requirements.

  • Charge Entry: The best optometric RCM solution takes the worry out of entering error-free insurance data before insurance claims are filed. Accurate charge entry is crucial so your practice can collect maximum reimbursements, decrease payment denials, and increase profitability.

  • Medical Coding: Certified medical coders have a good understanding of anatomy and physiology, disease process, and clinical procedures, which allows them to apply the correct billing codes and modifiers to medical claims. Also, when you outsource your medical billing and RCM services, you don’t have to worry about keeping up with certifications, staff vacations, unplanned sick days, turnover, or costly re-training.

  • Electronic and Paper Claims Submission: While every practice will experience claim rejections and denials, knowing how to prevent those rejections in the first place is the solution to receive revenue quicker. RCM partners, such as Fast Pay Health, make sure your medical claims are clean and free from errors before they submit them to insurance companies—delivering a consistent and positive cash flow for your practice.

  • Clearinghouse and Payer Rejections: Are you spending too much time verifying that the insurance payer is accepting the electronic claims you submit? RCM optometric billing consultants track all claims the practice submits electronically through a clearinghouse. If they notice a rejection, they promptly fix the errors to ensure timely receivables.

  • Daily Insurance Payment Posting: By posting remits within 24-48 hours, you can move the balance to secondary insurance and bill that much quicker. RCM optometric billing consultants post payments that come in through Electronic Remittance Advice (ERA) and standard paper Explanation of Benefits (EOB) directly into your practice management system, so you have accurate and up-to-date accounts.

  • Secondary Claims Filing: If a patient has secondary insurance, you can run into timely filing denials. Many payers require you to bill a secondary carrier within a specific period after you receive payment from the primary insurance payer. Or, if there was a balance left for the patient to pay, it becomes increasingly difficult to collect payments the longer it’s been since the patient’s visit.

  • Denied and Rejected Claims Management: Researching unpaid or denied claims is a time-consuming process. Once a claim is denied or rejected, most insurers set a deadline to contest the denial. It’s critical that you review all rejected or denied claims promptly to increase your cash flow. RCM services analyze all unpaid claims and EOBs, and take the necessary steps to correct and reprocess rejected claims to recover the maximum payment possible.

  • AR/Aging Claims Clean Up and Insurance Follow-up: Accurate information is directly related to you receiving reimbursements—claims get paid faster! RCM specialists analyze unpaid claims then take the necessary steps to recover the amount due. Outsourcing RCM services reduce the number of hours your staff spends tracking down payments with insurance companies, so you can see more patients and focus on other operational tasks.

  • Claims Auditing: Avoid delays in reimbursements with proactive medical claim audits—they are a vital component to benefit cost management. Audits will help you determine which RCM processes require improvements and corrections so you can improve the financial health of your practice. The best RCM services will review AR aging claims daily to see why open balances are still outstanding.

  • Processing Patient Statements: Are you having a difficult time keeping up with printing and mailing statements to your patients? Reduce expenses, boost your revenue, and eliminate the time-consuming task of in-house printing and mailing. The quicker you send out patient statements, the faster you get paid.

  • Quality Reviews: Are you cross-checking every revenue cycle management process to locate and correct a problem then checking to see that what you did works? RCM quality review teams monitor every step of the revenue cycle management process.

  • Business Analytics: Comprehensive reports analyze the activity and work completed, and they help measure and track your results over time. Analytics provide your practice with insight into business strategies that will help you move your practice forward and improve your financial performance.

Optometry Billing Services That Empower Your Practice

The Fast Pay Health end-to-end revenue cycle management approach is to triple-check everything so that you see a consistent return on your investment.

Our optometric billing consultants know the ins and outs of working with clearinghouses and insurance payers, and we take the time to research and analyze every process to maximize your payments—so you can focus on patient care.

Our service goes far beyond processing insurance claims. We provide a complete eye care billing solution tailored to your individual practice.

Ready to experience the positive ROI of outsourcing eye care billing? The Fast Pay Health team will help you get started on your way to increase productivity and business growth.