3 min read

How Well is Your Claims Management Solution Moving Cash Flow?

By Prime Care Tech Marketing on Fri, Dec 11, 2015 @ 06:58 PM

Claims Management Cash flowThat claims management has an impact on cash flow cannot be denied. But is your solution really working for you? First, let’s identify in what ways a claims management solution helps cash flow by converting into statements the questions found in our recent primeCLAIMS quiz, entitled, “Is Your Claims Clearinghouse a High Performer?”

Cash Flow


With your current solution you should be seeing cash flow improvements quarter over quarter. We suggest setting specific goals tied to claims-to-cash improvement and review progress at least quarterly. Contributing directly to cash flow improvement is measured improvement in your claims acceptance rate. The clearinghouse you choose should be able to help your AR team significantly reduce claims rejections conveniently. Occasionally, payers may request changes to the claims your team submits. A clearinghouse should help you turn those claims around quickly.

Take a close look at your clearinghouse and the middleware[1] it uses. We have learned from providers who use other clearinghouses that critically-needed application upgrades can take an unreasonably long period of time. Why? Because some clearinghouses do not own the middleware their application relies on and must wait for such changes. Owning the middleware certainly contributes to a quicker response to upgrade requests. 

We’ve mentioned this before, but with a clearinghouse experienced with post-acute payers and their claims processing technicalities providers are more likely to see improved claims processing and fewer frustrations. Such a clearinghouse is more responsive to LTC provider needs and in some cases the clearinghouse can anticipate needs and be ahead of the upgrade curve.

Productivity & Labor Savings

Considering turnover issues, the automated claims management solution needs to be intuitive - easy to learn and use for newly-hired and less-experienced billers. Further, with customized train-the-trainer programs and implementation, the clearinghouse helps providers to get new-hires up and running quickly while reducing orientation and training costs.   

The clearinghouse application must be robust with simplified reimbursement workflows and the users’ ability to manage claims submissions, denials, remits, DDE access, and HETS inquiries in a single portal. Further, being able to submit claims in batches reduces inefficient and costly steps. Should a payer reject a claim, the clearinghouse should be able to isolate the rejected claim and not reject the entire batch. Another example of possible key clearinghouse capabilities is the automatic identification and release of secondary claims. Secondary claims are a significant part of revenue to be collected yet are likely most at risk for non-payment.

Near and dear to any CFO’s heart are reports. Being able to view a dashboard of claims-related KPIs has proven valuable to provider management teams which can reinforce accountability throughout the entire claims management process.


From a strategic standpoint, having a clearinghouse partner that keeps up with LTC-specific regulatory changes across the senior care continuum and communicates them to its provider partners is important. In primeCLAIMS, customers are able to view updates and notices in their dashboards – a convenient way to anticipate and prepare for changes.


Being in total control of who has access to which features, functionalities, and reports gives providers the control they want over the claims flow process. Such security capabilities give corporate, region, and facility managers the flexibility they need to view all locations for which he or she is responsible in aggregate and individually.

Enterprise Effectiveness

Sometimes the term “enterprise class” is overused, but in the case of claims processing, this term is meaningful. With some clearinghouses, management can only view claims’ status one facility at a time. Being able to aggregate (at the corporate or region level) and drill down to specific facilities in one portal gives managers both a high-level and, if they choose, an in-depth view of pending, outstanding, and paid claims.

A clearinghouse should not only upgrade its application and best-practice recommendations based on regulatory and payer-specific changes, but also listen to current customer needs and requests to improve customer productivity. If the clearinghouse appears to be unresponsive or slow to respond, that should be a concern.


We recommend that you carefully evaluate your current claims management solution to see if it is effectively helping you move cash into the bank. It just makes cents.

[1] “Middleware is a general term for software that serves to "glue together" separate, often complex and already existing, programs. Some software components that are frequently connected with middleware include enterprise applications and Web services.” TechTarget, http://searchsoa.techtarget.com/definition/middleware, Margaret Rouse

Claims Process

Topics: automated claims management cash flow clearinghouse Medicare claims claims middleware claims submissions secondary claims reimbursement workflows application upgrades compliance security
3 min read

Clearinghouse Support – Is It There When You Need It?

By Prime Care Tech Marketing on Thu, Dec 03, 2015 @ 11:00 AM

Clearinghouse SupportClaims processing automation significantly contributes to a smoother claims flow and quicker conversion of revenue to cash. The key component to claims automation is the clearinghouse which scrubs the claims and then securely transmits the claims to the payer. That sounds simple and it is MUCH simpler than any other method of submitting claims and it’s HIPAA-compliant. However, claims are submitted electronically and that means software. Where there’s software, there are computers. And where software and computers exist, there is the chance that users may need to contact the clearinghouse for questions regarding software administration, functionality, training, and support.

Whether a provider is considering clearinghouse options or has already contracted with one, the following tips may help them conduct a more useful support services due diligence:

  1. Response time – Time is money and especially with claims processing. Whether the call is a how-to or a break-fix question, getting answers or problems resolved in a reasonable period of time is critical. How supportive is the clearinghouse’s team? What hoops do users have to jump through in order to get answers?
  2. Tip: Be specific with the types of questions. Some questions or issues, such as password resets, can be addressed in a matter of moments, while others may require more time for resolution.
  3. Knowledge of the industry – LTC providers confront a daunting task when filing claims and not all clearinghouses understand the nuances inherent in LTC claims.
  4. Tip: Finding a clearinghouse that understands the world of LTC claims is key to usability, satisfaction, and the results providers need.
  5. Who owns the software – There is this magic component called middleware that makes an electronic claim possible. Some clearinghouses will claim to own the software (the user interface) but they do not own the programming that actually transmits the claims. Those who do are more likely to respond quickly to requests for changes and fixes to their software than those who don’t. In our experience, it can be a matter of days compared to weeks or months.
  6. Tip: Find out how nimble the clearinghouse is in response to requests.
  7. Rooted in the LTC community – This ties in with item #2. Clearinghouses, whose customers are primarily acute care providers or physician practices, are more inclined to accommodate customer requests from those verticals than from LTC providers who may only represent a small portion of the customer base. It’s a matter of the 600 lb. gorilla. LTC is just harder to understand and develop solutions for than acute care and physician practices.
  8. Tip: Each clearinghouse has its own strengths and weaknesses. Check LTC references to confirm each clearinghouse’s claim of LTC claims expertise.
  9. Technology investment – The rules of LTC claims game are constantly changing. Is the clearinghouse keeping up? Also, does the clearinghouse support efficient practices? Take for example, claims batching. Batching claims is good, but beware. Some clearinghouses will reject all claims in a batch even if only a few are truly rejections. To avoid this, billers will submit claims one at a time which is unnecessarily inefficient.
  10. Tip: Make sure that the clearinghouse can isolate, exclude, and reject only the rejected claims.
  11. Never mind technology; it’s still people working with people – How are callers treated when they speak to a clearinghouse representative? Ultimately, customer service is still the king of satisfaction.
  12. Tip: Check the references for this important aspect of a clearinghouse’s service.

The bottom line? Scrub your clearinghouse options before you let any of them scrub your claims. And when it comes right down to it, what really differentiates one from another is the level of support offered. Happy billers and productive billers. And getting the support they need, makes billers happy.

It just makes cents.

Claims Process

Topics: clearinghouse claims HIPAA support services software training and support


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