Medical Billing Clearinghouse

What is a medical billing clearinghouse and how to select the best? Learn the benefits of using a clearinghouse and what to look for before selecting.

What is a Clearinghouse
Medical billing clearinghouses take claim information from a billing service or provider, check the claims for errors, and send this claim information electronically to insurance companies. Claims sent electronically are paid much faster than paper claims.

The Benefits of using a Clearinghouse are:

  • Claims are sent electronically reducing postage and paper
  • Reduces claim errors
  • Sends claims to several different insurance payers
  • Sends a large number of claims quickly
  • Reduces time to get paid

So Many Software Vendors
There are so many different medical billing software vendors. Each vendor creates a claim file in a different format. It may be an ANSI file or a print image file or a variation of these. Each insurance payer has different requirements for submitting electronic claim files.

The medical billing clearinghouse takes the claim file from each client and translates or re-formats it into a common format acceptable to the insurance carrier. This is usually done in batches on a regular basis.

Checked for Errors
These claims are created in an electronic file using billing software. The file is then uploaded to the clearinghouse where it is “scrubbed” to check for errors and make sure all the necessary information is in the claim. This allows a chance to correct the claim and resubmit. Once accepted the claims are transmitted electronically in a HIPAA standard secure format to the insurance payer.

Payers the clearinghouse is not contracted with are usually dropped to paper claims which the clearinghouse mails for you. It's important to make sure the medical billing clearinghouse you select has an agreement with the payers a provider uses the most. Otherwise you end up paying extra for them to print and mail paper claims.

Insurance Company Processing
The insurance company receives the claim batch and either accepts or rejects the electronic claim. They send claim status back to the clearinghouse which then provides the status to the user - usually in a report format - that the claims have been successfully transmitted and received. If a claim is rejected, it will require correction and re-submission. If everything is acceptable for the insurance payer, usually within 2 weeks (longer for Medicare/Medicaid) the provider receives a check accompanied by an Explanation of Benefits (EOB).

To submit claims electronically without a clearinghouse, you would have to submit to each individual insurance company. This would be a major hassle as it requires a lengthy verification process with each carrier to get the unique submission requirements worked out with each one having different requirements. Can you imagine doing this for each payer? Submitting claims to individual insurance payers is a very time consuming and labor intensive process.

Selecting a Medical Billing Clearinghouse
A good clearinghouse should have a large payer list, be reasonably priced, and have good technical support. Make sure all the insurance companies you submit most of your claims to are included. Stay away from a clearinghouse that requires a long term contract or penalizes you to terminate service.

Make sure the clearinghouse can accept claim files in the format your billing software generates. This claim file is usually in a print image or ANSI format. The Lytec software we use creates a print image format file. We also use AltaPoint software which creates an ANSI 4010 format file. These file formats are worked out with the clearinghouse when starting service. You submit a test claim first to make sure the clearinghouse receives all the claim information properly.

The clearinghouse then maps this file into a format that allows them to transmit it to various insurance payers. This is where having a clearinghouse with good technical support is important. Otherwise you end up with the clearinghouse saying you have a software problem and the software vendor saying you have a clearinghouse problem. And all the while you're not getting any claims submitted.

Technical Support is Important
Occasionally we have issues with errors in our claim file format – it gets corrupted or somebody gets in the software (who shouldn’t be) and messes things up. Having someone who can help you resolve these issues is invaluable. Paying more for a medical billing clearinghouse is worth it if they have good technical support. When we have a problem submitting files, we need to get it resolved as soon as possible because it means our provider isn't getting paid, and we're not getting paid.

I've always used ENS Health and had good results with them. We've had problems - especially with NPI transition in 2008. But ENS has helped us to work through these quickly – and they were overwhelmed with customers having the same problems. They are prompt to return calls and work with you to resolve problems. Their technical support folks have the capability to remotely log onto your PC which really helps in resolving problems quickly.

Expect to pay between $75 and $125 per month for a good medical billing clearinghouse. They may require a setup fee but it's usually not unreasonably high. Some charge per claim while others charge a fixed fee for unlimited claims.

Other Clearinghouse Services
Most clearinghouses also offer other services such as:

  • Patient statements
  • ERA
  • Eligibility Verification
  • Patient payment processing

We use the patient statements service our clearinghouse ENS Health offers. This has proven to be a tremendous time and money saver. We send an electronic file with all our patient statements and they print and mail the statements in a professional format with return envelopes. They also have the ability to check addresses. Printing, sorting, and mailing patient statements is a very labor intensive process. It ends up saving us money as the cost per statement is actually less than if we do it ourselves.

I've also used the ERA services. This allows us to retrieve the EOB without waiting to receive it from the provider. Some software programs have the ability to post the electronic ERA in the software but I haven’t had much success with this. It seams like we spent as much time cleaning up after electronic posting than just manually posting payments.

Here's a partial list of some of the clearinghouses I checked out before committing to ENSHealth. I really recommend ENS Health based on years of good service from them and their reasonable pricing.

  • ClearConnect
  • Emdeon
  • ENS Health
  • Envoy
  • ET&T
  • Gateway EDI
  • Healthfusion
  • iPlexus
  • ZirMed



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