9 Essential Questions Revenue Cycle Leaders Should Be Asking About Their Claims Clearinghouse Vendors
May 24, 2023
Welcome to the world of healthcare revenue cycle management, where every aspect of your business is crucial to success. It’s not just about having any partner but having the right partner that can make all the difference. At times, settling for a vendor that is simply “good enough” might seem like the easiest option, but it can ultimately hold your organization back from reaching its full potential.
As hospitals and health systems face mounting challenges, such as declining revenue and workforce shortages, the importance of having a reliable and efficient claims and clearinghouse partner cannot be overstated. Your organization deserves a partner that goes above and beyond to optimize resources, maximize reimbursements, and streamline processes. So, how do you decide if it’s time to part ways with your current vendor or stay the course? In this blog post, we’ll explore the crucial questions you need to ask to ensure that your claims and clearinghouse partner is not just good enough but the perfect fit for your organization’s success.
1. Is your vendor’s edit suite advanced enough that it consistently catches errors and supports compliance on claims before initial submission? How does the depth and breadth of their edit suite contribute to successful claim processing?
It’s crucial to inquire about the breadth and depth of the vendor’s edit suite, including the experience and tenure of their edit team. A comprehensive and advanced edit suite should encompass a wide range of industry-specific, payer-focused, and provider-targeted edits skillfully managed by a team with a significant number of years of experience and a proven track record in the field. This ensures that the vendor can effectively handle the complexities of the healthcare industry, accommodate evolving payer policies, and cater to the unique requirements of individual providers.
A comprehensive edit suite combined with the team’s experience demonstrates the vendor’s commitment to staying current with industry standards and regulatory updates, ultimately leading to a more efficient claims process and a higher success rate in claim reimbursements for your organization.
2. How easy is it to get in touch with your vendor when you need them?
Does your team have to wait for days or even weeks to get answers and come up with a resolution? Time is money and you need a true partner that’s highly responsive and doesn’t have to weed through tons of red tape OR layers of internal bureaucracy to get you and your team the help they need when they need it. A responsive vendor showcases their commitment to your organization’s success by truly building a partnership with you and helps minimize disruptions in your claims process.
Evaluating your vendor’s support offerings can also reveal how efficiently they handle urgent issues or escalations, including system outages or critical claim processing errors requiring immediate attention. A vendor that resolves such issues quickly and effectively not only reduces potential financial impacts but also maintains the overall productivity and morale of your revenue cycle team.
When assessing a vendor’s support capabilities, it’s essential to examine their communication channels and escalation procedures. This involves understanding the reporting process for issues, how your organization will be informed about resolution statuses, and whether dedicated support teams are available for specific concerns. A vendor with a well-organized support system and transparent communication processes ensures your organization can rely on them when needed, fostering a robust partnership grounded in trust and dependability.
3. Can the vendor enroll payers in 30 days or less?
When selecting the right claims and clearinghouse vendor, it’s crucial to understand their approach to enrolling you with your payers, particularly your top payers, within a defined timeframe. Efficient enrollment with your payers ensures seamless integration with various payer systems, accelerating claim submissions and reimbursements.
Your vendor should collaborate closely with your organization to identify and enroll you with all relevant payers, prioritizing the enrollment with your top payers in 30 days or less. This demonstrates their ability to address your organization’s unique needs and adhere to set timelines. Furthermore, the vendor should have the expertise to navigate payer-specific requirements and keep enrollment information up-to-date, preventing any delays or disruptions in the claims process.
4. How effectively can the vendor cater to large, enterprise-wide, multi-location organizations, particularly in processing remittances and ensuring accurate allocation of remits to the correct location?
While many vendors can support smaller, less complex organizations, not all are equipped to handle the challenges posed by larger organizations with multiple locations and intricate operational structures. When evaluating a claims and clearinghouse vendor, it’s crucial to assess their experience in managing the unique challenges faced by such organizations, including coordinating workflows, integrating disparate systems, and maintaining consistency across locations. A competent vendor should have a successful track record in this area, demonstrating their ability to scale their solution and services to meet the diverse needs of large, multi-location organizations while ensuring streamlined revenue cycle management and optimal financial performance.
Additionally, it’s vital to inquire about a vendor’s experience and capabilities in managing remittance processing for larger organizations. In more complex environments, such as large hospitals with multiple Tax Identification Numbers (TINs), accurate allocation of remits to the correct location is essential for efficient revenue cycle management. An adept vendor should have a system in place to accurately identify and track remits based on TINs and other identifiers, ensuring that payments are correctly allocated to the appropriate location. This capability not only streamlines the remittance process but also minimizes the risk of errors and delays in payment reconciliation, ultimately contributing to a more efficient and effective revenue cycle.
5. Can the vendor demonstrate proficiency and proven success in managing claims for complex cases/patient visits?
It’s crucial to partner with a claims and clearinghouse vendor that can easily handle complex claims. Complex claims often involve multiple services and various payer requirements. Typical examples include out-of-network claims, high-cost procedures and treatments, trauma cases, multi-day inpatient stays, co-morbidities and complications, and clinical trials and experimental treatments. These types of claims require a vendor with a deep understanding of the intricate claims process, various payer requirements, and regulatory compliance.
Ask current and potential vendors about their experience managing complex claims, as well as their success rates and average processing times. A proficient vendor should be capable of handling these claims by leveraging their expertise, technology, and industry knowledge. Furthermore, the vendor should continuously monitor and update their systems to accommodate evolving industry regulations and payer policies.
Ultimately, a top-tier vendor will act as a trusted partner, providing support, insights, and ongoing improvements to help healthcare providers confidently and easily tackle even the most challenging claims.
6. Can the vendor seamlessly integrate or interface with your existing systems, including the ability for staff to work medical claims directly within your core HIS when available?
Seamless integration of claims management systems is essential for efficient revenue cycle management, and a top vendor should prioritize this aspect of their service. An ideal partner should ensure their claims management solution interfaces or integrates as extensively as your health information system (HIS) is capable.
By enabling the effortless transfer of claim information, the vendor can help reduce errors, streamline workflows, and enhance overall efficiency. Additionally, the vendor should provide support for implementing and maintaining these integrations, including troubleshooting and timely updates to accommodate evolving industry standards and regulatory requirements. By fostering a well-integrated claims management environment, the vendor can facilitate a more effective and transparent revenue cycle process, allowing healthcare providers to focus on delivering the best patient care.
Inquire about how easily the vendor’s platform will integrate with your existing infrastructure, as well as any potential challenges.
7. What measures does the vendor take to ensure a seamless implementation and training process, and do they provide various training options to accommodate different team schedules?
Many vendors claim to hold your hand throughout the entire process but often fail to deliver. To avoid disappointment and setbacks, it’s critical to thoroughly understand the steps and timeline involved in the vendor’s implementation and training process as well as any potential roadblocks that may arise during the transition.
When evaluating a vendor’s implementation process, inquire about their approach to onboarding and training your team. This should include details on how they will deliver training, provide hands-on guidance, and offer ongoing support to ensure your team is well-equipped to navigate the new system. Keep in mind it’s important to consider their flexibility in providing live and on-demand training sessions that cater to various learning styles and schedules. The vendor should also have a clear project plan and timeline, with milestones and checkpoints to track progress and ensure all parties are aligned throughout the implementation.
The vendor’s ability to minimize disruption during the implementation and training process is a critical factor in ensuring a smooth transition. This involves providing dedicated support teams that can address issues and concerns as they arise and maintaining ongoing communication with your organization to keep you informed of progress and potential challenges.
Finally, consider how the vendor addresses challenges during the implementation and training process. A well-defined contingency plan and established escalation procedures indicate their preparedness to handle unexpected roadblocks and ensure minimal disruption to your operations.
8. Can the vendor demonstrate their long-standing client satisfaction and the enduring value of their partnerships, especially with clients who have been with them for over 20 years?
When assessing a claims and clearinghouse vendor, it’s crucial to consider their reputation and the experiences of other long-term clients. Requesting client testimonials or references, particularly from those who have partnered with the vendor for 20+ years, can offer valuable insights into the vendor’s performance, service quality, and ability to cater to organizations similar to yours. Moreover, evaluating feedback from other clients can help you identify the vendor’s strengths and potential areas for improvement, ultimately enabling you to make a well-informed decision about their suitability for your organization.
It’s also worth considering the satisfaction and loyalty of the vendor’s associates, as their commitment and enthusiasm for the company can translate into higher quality service and support for your organization.
9. How effectively does your vendor’s reporting and analytics tools address payer behavior and enable predictive cash flow management?
If you find it challenging to extract vital payer metrics from your core HIS/EHR system, you may want to consider an analytics tool offered by a reputable claims and clearinghouse vendor. An advanced claims analytics solution can reveal payer behavior trends, providing easy access to payer data and actionable insights that promote well-informed decision-making.
With the right tool, you can examine claims, remits (denials), and other revenue cycle data across multiple payers to drive meaningful conversations internally and with specific payers. Ultimately, you should leverage data as proof to show payers where they may be under-delivering, hold them accountable, and act as a driving force to initiate change.
Additionally, the solution should offer predictive cash flow capabilities that go beyond when providers can expect the remit—but also predict the value of the reimbursement!
A robust and intuitive claims reporting and analytics tool should provide actionable insights to foster informed decision-making, drive meaningful conversations with payers, and maximize revenue potential.
There’s no better time to evaluate your claims and clearinghouse partnership and determine if it aligns with your organization’s needs and goals. Start today by asking the right questions to ensure you have the proper foundation for your organization’s success.
To learn more about SSI’s industry-leading claims management and clearinghouse solutions, contact us today.
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