Medical Clearinghouse Support


Medical Billing Service – Decision Guide

Outsourcing billing is a smart way to maximize claims revenue in your practice. Professional billing services can improve the accuracy and efficiency of your back office systems, maximizing revenues through reduced billing errors and fewer unpaid claims. The challenge is in finding the right medical billing service for you – one that aligns with your practice goals and is easy enough for your team to use to its fullest potential.

Types of Medical Billing Outsourcing

There are two primary options with regard to the type of medical billing outsourcing company you choose: a local service or a software solution. Each of these options has its pros and cons, but both should, ultimately, help you optimize back-office workflows and maximize revenue.

Local Medical Billing Service

Working with a company that is local to your practice provides some attractive benefits. You have the option of having billing personnel on-site to support your team during implementation and when issues arise. Personal relationships often improve accountability as you will always have a key person to liaise with in case there is a problem, and it’s easier to establish a personal relationship between your team and theirs. This option may appear more expensive because this service bundles both the billing labor and their software licensing.

Software-Based Medical Billing

Medical billing software and service coupled with an EHR software-based solution gives you better potential for integrating with your current back office technology. It ensures that claims are processed quickly and efficiently; additionally, coding accuracy and payment timelines are much-improved. One drawback is that you have less customization options and personal touch – you will adapt your practice to the software service rather than the service adapting to your practice.

Shopping Considerations

As you are shopping for medical billing vendors, factor in several dimensions to your buying criteria :

  • Technology: Learn which electronic claims clearinghouse the billing service uses and more importantly, find out how they use this technology to solve your practice’s unique issues
  • Resubmissions: Find out whether the company charges for resubmissions and what their process is. If you end up with a lot of denied claims, this alone could make the service less financially viable in the long run.
  • Data Security: It should go without saying that your medical billing outsource company should be fully accountable to HIPAA data security regulations and compliance protocols
  • Data ownership: If you should choose to go with another company at any point, you want to ensure that you can easily transfer your data to the new vendor without complications.
  • Trial Evaluation: Ask the billing company if they support trials before a full time commitment, and gauge their actual performance against their advertised improvement
  • Pricing: In-house billing is typically fixed cost per labor-month versus outsourced billing is often a percentage of collected revenue – Ask
  • Extra charges: Be sure you are aware of what’s included and whether there will be any “hidden fees” or extras charged back to you, e.g. implementation fees, termination fees, monthly minimums
  • Terms and termination: Service companies put a lot of front-end time on-boarding new medical practices and thus require 3-12 month minimum terms to recoup their investment, find out how long their minimum term length is
  • Integration: A software service will be intimately integrated with your existing administrative systems and a reputable service will have a well-documented implementation plan

Medical Network for Payers Reduces Costs
and Aids Market Entry and Plan Design

Eligibility and Patient Access

According to the 2016 CAQH Index, health plans could save $649 million a year through electronic eligibility and benefit verification.1

Medical Network for Payers connects payers to hundreds of provider workflow applications to communicate critical coverage details. Self-service provider tools enable providers to find the information they need themselves, without resourceconsuming calls into the payer support desk.

  • Eligibility inquiries (270 / 271)
  • Referral authorizations and notifications (278)
  • Hosted data solutions for both eligibility and referral authorizations

Claiming and Remittance

Medical Network for Payers digitizes the claiming and remittance cycle with hundreds f thousands of providers in local and national networks.

Claims Management can help improve efficiencies, reduce rejected claims and shorten the adjudication process.

Electronic Attachments eliminate paper. Advanced editing enables payers to reject or pend claims submitted without required attachments.

Claims Status provides visibility from submission to payment, reducing payer support desk calls.

Electronic Remittance Advice (ERA) can help eliminate printing and mailing paper remits, and reduces provider calls.

The Availity advantage

Healthcare is complicated, but your relationship with your clearinghouse vendor doesn’t have to be. When you entrust Availity to manage your healthcare transactions, you not only get the peace of mind that comes from working with an industry leader, but you get our deep industry expertise and commitment to customer service. No matter how large or small your organization, our EDI Clearinghouse solution gives you access to our nationwide network, along with flexible contracts and competitive pricing.

The Availity Network: Your Connection to Payers Nationwide

Availity is the nation’s largest real-time health information network with connections to more than 2,000 payers nationwide, including government payers like Medicaid and Medicare. Because many payers in the Availity network sponsor EDI transactions through Availity, we only pass on transaction fees to submitters when necessary. As a result, we can offer the largest network of free transactions in the industry, as well as competitively priced access to the rest of the payer market. To see all of the payers in our network, visit our Payer List.