Clearinghouse & Chiropractic Data Resource Center
Electronic Claims Processing and Chiropractic Clearinghouses
Electronic processing of billing claims speeds up the payment and reimbursement process by allowing clinics to identify and correct claim errors early. Initially, chiropractic clinics had to wait until paper-based claims arrived through the mail and were processed before they knew if they were billing correctly. Now that insurance billing is largely an electronic process, companies called clearinghouses serve the vital function of reviewing claims before sending them along to the insurance company.1
From there, the clearinghouse notifies the clinic if they find any mistakes or reasons why the insurance company might reject the claim. The clinic can then fix the claim and resend it. Claims that are error-free are sent directly to the insurer. This whole process is usually faster than traditional, paper-based methods or waiting for a claim rejection and return.
Electronically-processed claims can be tracked through the clearinghouse's software, showing the clinic where the claim is located in processing. Claims can be submitted to the processor as a batch. Insurers that submit an explanation of benefits (EOB) back to the clinic can do so electronically, saving additional time and paper. Payments approved by the payer are then sent to the clinic's bank account through electronic fund transfer (EFT).
Clearinghouses typically charge per claim submitted for review. Using the services of a clearinghouse usually requires high-speed internet access and compatible technology. The necessary software may be provided by the clearinghouse. Signing up for clearinghouse services should be seen as an investment, because the upfront costs can be significant. 1,2
Overall, many clinics benefit substantially from using a clearinghouse to process their claims. Electronic claims processing reduces administrative time, identifies potentially costly errors before they reach the payer and cuts down on the use of paper. With this service, you may spend less time wondering if you are billing correctly--this reassurance alone may very well be worth the added cost.¹
MACRA and MIPS: Value Based Care
Chiropractors and other healthcare providers that bill Medicare are now required to meet specific quality criteria set by the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).
This legislation allows providers to participate in the Merit-Based Incentive Payment System (MIPS) and, if they qualify, move up to the Alternative Payment Model (APM) system and become eligible for lump sum bonus payments. Most providers start out at the MIPS system.3
MIPS, along with the APM system, is part of the MACRA Quality Payment Program (MACRA QPP). Chiropractors who accept Medicare and participate in MIPS are measured on care quality, use of resources, efforts at improving clinical practice, and meaningful use of electronic health records (EHR).
Based on your practice's performance in these categories, you will either receive a bonus payment or will have a negative adjustment applied to your reimbursement. To avoid the negative adjustment, you will need to carefully track your own performance in the MIPS categories and make improvements.3
These scores are intentionally flexible, allowing for exceptional performance to be rewarded and for specific circumstances to be judged as fairly and equitably as possible. Within the categories, different measures are available.
Clinicians may choose some of the measures apply to them based on their specialty, clinic location, size of practice, and other factors. Through reporting performance in these areas, your payment adjustment is calculated based on the prior year's score. A better score this year improves your adjustment next year.4
Some chiropractors are exempt from MIPS. Physicians in their first year of Medicare B participation are not subject to the program, for example. Those who see fewer than 100 Medicare patients per year and receive less than $10,000 annually in Medicare reimbursements are also exempt, as are Advanced Alternative Payment Model (Advanced APM) participants.
If one of these exemptions applies to you, then you likely are completely exempt from MIPS. If you are unsure about the MIPS requirements, be sure to do your own research and obtain advice from a compliance professional.4
Regulatory Compliance and the chiropractor
Healthcare is a tightly-regulated industry and chiropractors have rights and responsibilities connected to their practices. Compliance with federal, state, and local regulations is an absolute must for chiropractors who want to provide the best care possible and operate their clinics legally.
Some regulations are relatively well-known, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA governs such diverse issues as patient records privacy, record security, and electronic health records (EHR) standards.
Others, such as the newer Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) are less familiar. MACRA regulations apply to many of the clinics that see Medicare beneficiaries. Other regulations exist from local, state, and national levels of government.5
For many physicians, compliance is a cumbersome topic. Instead of becoming intimidated, clinics should seek reliable advice about how compliance issues apply specifically to them.
Compliance advice must be tailored to each practice, because different regulations may apply in each situation. Clinics with more than one staff member can designate compliance champions and smaller clinics can devote time to researching compliance issues or obtain outside help from compliance experts.
Anyone who is uncertain about compliance should consider seeking professional advice, because this is such a vital part of clinic operations. 6
Using certified EHR software can also assist with compliance, since most vendors regularly update their systems to comply with new regulatory changes. Using EHR can be a great risk management strategy and can help you prevent human error from harming your reimbursements and your practice.
Much of the compliance environment is related to the use of patient records, transmission and storage of patient information and billing and coding. For these areas, EHR can help with the daily details of staying compliant. 7
From there, ongoing audits can help you protect your practice. Professional auditors can help conduct the audit directly, but you can also conduct audits yourself to help you find potential problems.
The American Chiropractic Association offers a self-audit toolkit you can use to review your clinical compliance and identify potential regulatory issues.
Recent Articles & News
Using Data and Analytics
Even small chiropractic clinics can now use data and analytical tools to reduce their costs, improve patient care and become more efficient. As you see patients, record information and submit billing claims, you are gathering data.
Without a way to systematically look at this information, it is difficult to draw accurate conclusions and determine how you will run your business and care for your patients. Data and analytics provide you with the means to understand what is happening at your practice.
From there, you can make corrections if you need to change course, or charge ahead if you like the results.8
Searching for trends
Simply put, data and analytics tools allow you to look for patterns and trends in the information you gather.
For example, if your EHR reporting function provides you with information about a subgroup of your patients or if your billing software tells shows you a troubling revenue trend related to a specific insurance company, you can then devise strategies to address these problems.
You might try to find out why some of your patients are coming in more frequently this month than they normally do, and you might review your billing system or find out why that insurer is denying more of your claims. Data and analytics can help you notice potential financial and patient population problems before they become much worse.8
Analytics enables you to drill down data and identify causes. Rather than wondering why your practice is struggling financially, for instance, you could locate areas where your practice is losing money.
Personalizing care becomes easier, too, when you can identify patients with similar ailments and track over time how well specific treatments are working. Data and analytics help you personalize everything about your practice.8
Software that helps with data analysis for healthcare practices is becoming more common and increasingly cheaper, so you may decide to purchase access to a computer program designed to help with your data.9
If you prefer analyzing the data yourself, begin by looking for patterns. For instance, try identifying your high-risk patients and look closely at trends.
If you find something interesting, discuss it with your colleagues, remembering to follow privacy and HIPAA regulations. By beginning to work with data, you will likely find some basic strategies for growing your practice, reducing costs, and improving patient care.9
Content Written By Kaitlin Morrison
1. AMA and CSMS. "The benefits of electronic claims submission--improve practice efficiencies." stepsforward.org. The American Medical Association and the Connecticut State Medical Society. https://www.stepsforward.org/Static/images/modules/20/downloadable/claims-flyer.pdf. Published: 2013. Accessed: September 2016.
2. mb-guide.org. "Guide to Medical Billing Clearinghouses." MB-Guide. http://www.mb-guide.org/medical-billing-clearinghouses.html. Accessed: September 2016.
3. cms.gov. "MACRA: Delivery System Reform, Medicare Payment Reform." Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed: September 2016.
4. cms.gov. "Merit-Based Incentive Payment System: Clinical Practice Improvement Activities Performance Category." Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/CPIA-Performance-Category-slide-deck.pdf. Accessed: September 2016.
5. hhs.gov. "HIPAA for Professionals." U.S. Department of Health and Human Services and the Office of Civil Rights. http://www.hhs.gov/hipaa/for-professionals/index.html. Accessed: September 2016.
6. Rosen, Mike. "3 Ways a Healthcare Compliance Officer Makes Organizations Healthier." The Provider Trust Blog. http://blog.providertrust.com/blog/bid/353994/3-Ways-a-Healthcare-Compliance-Officer-Makes-Organizations-Healthier. Published: April 2016. Accessed: September 2016.
7. healthit.gov. "About the ONC Health IT Certification Program." Office of the National Coordinator for Health Information Technology (ONC). https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program. Updated: August 2016. Accessed: September 2016.
8. Barron, Matt. "Big Data for the Small Practice." Advance Healthcare Network For Health Information Professionals. http://health-information.advanceweb.com/Features/Articles/Big-Data-for-the-Small-Practice.aspx. Published: March 2015. Accessed: September 2016.
9. Pittman, David. "5 Ways Doctors Can Use Data Analytics." MedPage Today. http://www.medpagetoday.com/meetingcoverage/himss/44541. Published: March 2014. Accessed: September 2016.