We’ve seen a trend recently concerning provider’s offices indicating that coverage isn’t active or that a claim is rejected due to eligibility.  It is very frustrating to then contact the carrier who confirms coverage is active and/or there are no claims on file.  What is happening?  It turns out providers use third party vendors called medical clearinghouses to submit claims.  A medical billing clearinghouse is a go-between for healthcare providers and insurance companies. A clearinghouse assesses medical claims, checks for errors, and processes them correctly. Once the clearinghouse has established that a claim is clean, it can be submitted for payment.

This is all well and good until the clearinghouse gives out incorrect information!  These clearinghouses do not even allow the claim to be submitted if their system doesn’t show a “clean” claim or coverage.  Some providers may file a claim directly with the carrier, but others cannot/will not file unless the clearinghouse okays the claim submission.  You may have heard of Change Healthcare.  They are one such clearinghouse which suffered a significant data breach earlier this year and was completely shut down for months.  This caused a huge tsunami of claims issues within the health care industry and made national news due to the extent of disruption within the health care industry.

Why are we sharing this with you??  If your staff is told by their provider that their coverage is not active or there is an eligibility issue, they need to ask if this information is coming from the carrier directly or the provider clearinghouse.  If from the clearinghouse, the provider’s office should contact the carrier directly for confirmation of coverage and then have a conversation with the clearinghouse to resolve the issue.  As always, please don’t hesitate to contact your Pender & Associates team if you have any questions about this specific concern or others related to your employee benefits.