What is a Clearinghouse?
Simply stated, a clearinghouse is a website that takes electronic claims information and sends it to partner health insurance companies.
At my physical therapy practice we might treat patients with 17 different insurance plans in a day. Our billing software will generate health insurance claims for physical therapy services in the form of ANSI 837 files.
I send that ANSI 837 electronic file to a clearinghouse who then divides up the claim information and sends it to the appropriate insurance carrier.
It allows my physical therapy practice to send one file to our clearinghouse and then that clearinghouse checks for technical errors and sends the appropriate claim to the appropriate insurance carrier.
Our clearinghouse also accepts ANSI 835 payment files from insurance companies and allows us to download and import that payment information directly into our billing software.
Does Medicare Require Physical Therapists to Use A Clearinghouse
Each Medicare MAC may have different guidelines and requirements for claim submission.
For example, in Florida, a physical therapist can not create a claim using SPOT. In this case a provider would need to submit claims via paper CMS 1500 or using a Clearinghouse like Office Ally or Availity.
However, in Ohio, a physical therapist may use the MyCGS MAC portal to create a claim and submit that claim for reimbursement. This is a free service provided by CGS.
How much do Clearinghouses Charge
Each clearinghouse will have a different pricing plan.
Office Ally allows providers to submit 10 claims per month free. If a provider submits more than 10 claims per month then they charge $35 per rendering provider if more than 50% of claims go to non-participating insurance carriers.
Other clearinghouses may charge per claim regardless of rendering provider.
Which is better?
It really depends on your business model. If you employee many rendering providers and each of them only generate a couple claims per month then you would be better to choose a pricing plan that charges per claim.
On the other hand, if you employ one rendering provider and that provider generates many claims per month you are better to choose a plan like Office Ally.
How do I find pricing information?
The best way to find the most current pricing information is to simply call the clearinghouse customer support line. From my experience, it is challanging and nearly impossible to get pricing information on thier website.
Which is the Best Physical Therapy Clearinghouse in 2022
The best physical therapy learinghouse depends on what is best for your physical therapy practice.
In my practice I only employee one physical therapist and two physical therapist assistants. This means the most economical choice is Office Ally.
If you are using an EMR software and your EMR software integrates with a single clearinghouse then you don’t have any other choice.
There may still be some clearinghouses that don’t partner with certain Medicare MACs. Be sure to check with your clearinghouse before signing on.
I would say in my experience they all do a great job delivering claims, accepting payment remits, and doing what you would expect.
Anthony Maritato, PT
Private Practice Owner / Physical Therapist
After starting a private practice physical therapy clinic in 2022 with his wife Kathy Maritato, PT, Tony and Kathy grew their practice to five locations across two states.
Now, Tony and Kathy enjoy spending time treating patients in the morning, coaching therapists in the evening, and being home to play with their dog Tucker and 4 boys.