Why Clearinghouses are Underrated as Key Enablers of Healthcare Interoperability

Clearinghouses are more than just utilities for moving claims from provider to payer.  They are integral to improved healthcare interoperability and the quest to extract valuable insights from clinical and administrative data.

When talking about interoperability in healthcare, clearinghouses aren’t always the first thing that comes to mind. For many years, the conversation has been much more focused on the exchange of purely clinical data from one provider to another – a challenge that is still only partially solved even after decades of hard work.

While clinical data exchange is certainly vital to success for patients, health plans, and providers, it’s just the tip of the interoperability iceberg. Accurate claims data is equally important for making informed, proactive decisions about patient care.  

Claims data doesn’t just offer deep insights into everything from overall provider performance patterns and to an individual’s ability to engage with their care plan. It’s also essential for the day-to-day business of being a payer: reimbursing providers for the wide variety of services aimed at improving member health.

Clearinghouses are the technology that makes this all possible. By coordinating the secure flow of claims information between providers and health plans, clearinghouses quietly and steadily keep the $4.3 trillion healthcare industry humming along.

It’s easy to look past this type of “middleware” solution, especially when it works well enough to avoid causing any major issues. But skipping over clearinghouses during the interoperability discussion would be a mistake, especially as payers and providers start to engage with increasingly complex, unstandardized data sets and new types of clinical and financial partners in a more patient-centered, value-based environment.

It’s time to take a closer look at the clearinghouse as a fundamental enabler of trusted interoperability between trading partners and ensure that both payers and providers are maximizing the value of what these important platforms can do.

The crucial role of clearinghouses in healthcare operations

Every year, healthcare providers submit hundreds of millions of claims for patient services to thousands of health plans across the nation.

Just building the electronic pipelines to shuffle all this data back and forth each day is a monumental task. Making sure that the information is accepted and processed in a standardized manner, correctly integrated into a health plan’s internal reimbursement systems, and returned to the provider in a timely manner with the right payment – or a clear explanation for denial – is even more challenging. 

Clearinghouses work in conjunction with electronic billing software to handle these processes digitally, proactively identifying common data integrity issues that may result in a denial or delay. Once a provider generates a claim using the standard 837 claim format, the clearinghouse accepts the file, scours it for any obvious errors, and sends it on to the correct health plan if it passes all the checks.  

The plan then conducts further analysis for clinical and administrative suitability of the claim and makes a decision on whether to reimburse as requested, deny outright, or ask for clarification.

The more sophisticated and trustworthy the clearinghouse, the less work has to be done on each side of the partnership. Robust clearinghouses with more automation, advanced analytics capabilities, and a trusted position within the health IT community are associated with lower overall denial rates and higher first-pass success rates, which is good for providers, as well as reduced administrative burdens on the payer side.  

The American Medical Association estimates that electronic clearinghouses can reduce the cost of claims processing by approximately 60 percent compared to similar paper-based workflows, freeing up time and capital to devote to other clinical or operational priorities.

According to CAQH, transitioning to fully electronic transactions could save the industry up to $25 billion per year, or 41 percent of annual spend in 2022.

Using clearinghouses to create a network of networks for better claims data exchange

A single clearinghouse cannot work in isolation, because health plans don’t just receive claims from their established, contracted in-network providers. They also get claims from an untold number of out of network clinicians from anywhere in the country.  

This can be challenging on several levels. First, reimbursement rates and requirements are different for these partners. Second, out-of-network providers may not be familiar with the correct formatting and data requirements necessary to get their claims adjudicated quickly. And third, without being directly connected to the prospective payer’s proprietary clearinghouse, these providers must simply trust that hitting “send” on their claim form will result in getting that information where it needs to go.

This is where the right clearinghouse solution can take interoperability to the next level. Clearinghouse vendors must work with their peers, trading partners, and competitors to ensure that all claims, no matter their origin, are routed to the appropriate recipient with as few gaps and errors as possible.

Data standards like ASC X12 Version 5010 make it possible for clearinghouses to assemble into “networks of networks” and make certain that any provider can reach any payer whenever necessary.

Fortunately, the ASC X12 standard is well established in the electronic data exchange community, and claims are typically highly structured documents with relatively few unknowns, making it easier for clearinghouses to engage in the type of interoperability that is often so elusive in the clinical data ecosystem.

Trust as the bedrock of interoperability between payers and providers

With trillions of dollars and huge volumes of sensitive clinical data shooting across the claims superhighways at any given moment, it’s essential that all parties involved have full and complete trust in their clearinghouses.

Choosing a clearinghouse with a strong reputation for security, service, experience, and responsiveness can turn an oft-overlooked piece of the interoperability puzzle into a valuable and proactive partner for improving clinical care and administrative efficiency.

A prospective clearinghouse solution provider should be able to demonstrate its mature and wide-reaching connections with peers across the industry to foster seamless interoperability for both in- and out-of-network claims. Platforms should also include process enhancements such as tools to generate cleaner claims, timely provider notifications at key steps in the process, and helpful resources to address any provider questions or problems that arise before or during claims submission.

With a trusted and collaborative clearinghouse, health plans and providers can work together more efficiently and effectively to accomplish their daily tasks while moving into the optimal position to take advantage of everything that rich, robust claims data has to offer. 

Clearinghouses shouldn’t just feel like part of the furniture. Instead, they should become an active and integrated part of a health plan’s larger interoperability goals. By simplifying and streamlining the claims submission process, clearinghouses don’t just save time and money for payers. They can also unlock the full potential of claims data for broader financial and clinical analytics purposes, such as provider performance monitoring, population health management, and other high-priority value-based care activities.

2022 HIT CONFERENCE

2022 HIT Conference

Presentations from the 2022 HIT Conference

Provider Education Track Presentations

Interoperability Track Presentations

Healthcare Landscape Track Presentations

Data and Care Delivery Track Presentations


About the Conference

Every patient deserves a full, dynamic portrait of their care story. We believe in our power to create a more vibrant and complete picture together.

The HIT Conference will feature four tracks with sessions covering topics like population health, interoperability, care delivery, and health equity, as well as popular sessions from previous PES conferences, like “Medicare Hot Topics” with Lori Weber and the Payer Panel. Join other healthcare professionals and attend sessions by esteemed speakers from the State of Utah, Office of the National Coordinator (ONC), University of Utah Health, Amazon Web Services (AWS), Noridian Healthcare Solutions, BYU, AUCH, Comagine, SLCo Health Department, UHIN, and more to be announced!

This event is tailored for professionals across the healthcare ecosystem, such as CEOs, CTOs, CIOs, Chief Medical Officers, VPs, directors, doctors, nurses, administrators, office managers, billers, educators and many more roles at health plans, hospital systems, providers, clinics, higher education institutes, and nonprofit organizations.

PES at HIT

For the first time ever, we’ve combined the annual Provider Education Summit (PES) and the HIT conference into a one-day, hybrid event. PES is an educational event for health plans and providers, billers, office managers, coders, administrators and more. PES will have a dedicated track, Provider Education, at the HIT conference this year.

Welcome Keynote

Rich Saunders

Chief Innovation Officer, Utah

Rich Saunders is Utah’s first chief innovation officer and is charged to help lead the Cox-Henderson administration’s commitment to aggressively upgrade state government efficiencies, innovations, and responsiveness to Utah residents, including a world-class customer experience initiative, and organizing the One Utah Health Collaborative nonprofit. Rich previously served as the executive director of the Utah Department of Health during the COVID-19 pandemic, and before state government, was an entrepreneur for 25 years with extensive experience in multiple verticals and significant sales networks nationwide. Rich has an ongoing passion for leadership, knowledge, organizational health, and service to his community.

Closing Session

Brittany Bowe

Olympic Speed Skater and Medalist

Three-time Olympian, Two-time Olympic medalist, 1,000-meter world record holder

Brittany Bowe led the way for Team USA as the flag bearer for the 2022 Winter Olympic Games in Beijing. She is a Three-time Olympian and Two-time Olympic medalist who gave up her spot in the 500m at the 2022 Winter Olympic Games for Teammate Erin Jackson – recognized as one of the most selfless acts in Olympic history.

1,000-meter world record holder… Reigning 1,000-meter season-long world cup champion… Won seven consecutive 1,000-meter world cup races from December 2018 to December 2019, the longest win streak by a U.S. woman. She helped end a 12-year U.S. women’s drought with an Olympic bronze medal in the team pursuit, and finished top-five in all four of her races at the 2018 Olympics. She is also a Six-time world champion, 20-time world championship medalist and 73-time world cup medalist.

As a gay athlete and LGBTQ+ advocate, uses her platform to promote inclusion and support others. She volunteers as an ambassador for nonprofits Right to Play and Athlete Ally.

Brittany suffered a concussion while training for the 2018 Olympics and was diagnosed with POTS, which means the body does not control blood pressure or heart rate after you stand up. She overcame her fear from that setback and, through an aggressive rehab program, returned to the podium.

Brittany previously played college basketball at Florida Atlantic University and won 32 world championship medals in inline skating before switching to ice. She is dedicated to maintaining a healthy balance between the physical, mental and spiritual aspects of life, and is working toward her yoga teacher certification. Also, Brittany is a cat owner.

Motto: “Practice doesn’t make perfect, perfect practice makes perfect!”

Tracks and Speakers

10:00 a.m. “A Novel Outpatient Complex Care Model – Using Claims Data for Risk Stratification and Evaluation”
Dr. Peter Weir | Executive Medical Director of Population Health, University of Utah Health

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A review of the Intensive Outpatient Clinic – highly coordinated and integrated care for Medicaid members with complex mental and medical health problems that result in high utilization.

11:00 a.m. “Partnerships to Increase HPV Vaccine Rates for Utah’s Community Health Centers”
Shlisa Hughes | Quality Improvement Director, AUCH

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AUCH is committed to preventing HPV related cancers through improving HPV vaccination rates. AUCH has partnered with Huntsman Center for HOPE, the U of U, Huntsman Cancer Center, the American Cancer Society and the UDHHS, and Utah’s Federally Qualified Health Centers to use automation and interoperability with clinical workflows to improve immunization rates for Utah’s youth. We will share results and innovations from across the state.

1:00 p.m. “Health Equity: Stop Talking, Start Doing”

Kassy Keen, MPH | Health Equity Bureau Manager, Salt Lake County Health Department

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Health equity has gained increased attention, resources, and support as COVID-19 and social justice movements transform our communities. Often we discuss health equity frameworks, which can be abstract and confusing, offering little guidance around implementation. So, what does it look like to incorporate health equity into systems, programs, and policies in the medical and health field? In this presentation, we will discuss operationalizing health equity, and explore a broad scope of tangible ideas to build capacity, and instill new processes, procedures, and data to create better outcomes for our communities.

2:00 p.m. Orion Health Presentation
Chad Peterson | Chief Revenue Officer, Orion Health

Sara Hallvik

3:00 p.m.Using Analytics to Improve Personal and Population Health
Sara Hallvik | Vice President of Data Solutions, Comagine Health

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Health data can be a powerful tool in improving both personal and population health, but one must consider several factors first. Data governance determines who and how data is used. Data quality determines whether results can be trusted. Combining data sources increases the complexity but can also increase the power of the data. This opens the way to descriptive, predictive, and prescriptive analytics, where one can harness their data’s true potential.

10:00 a.m.Why Are We Still Challenged by Identity Matching and Data Quality? Follow Oscar’s Patient Journey”
Gregg Church | President, 4medica, Inc.

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Access to accurate, complete, and timely data is one of the most valuable assets in any healthcare organization. The push toward value-based care and population health initiatives including the response to COVID-19 have amplified the need for efficient exchange of quality patient data, filling gaps in information and offering providers and payers a more complete picture of the patient. Quality data improves care coordination, clinical outcomes, and saves lives but can only be achieved with accurate patient identification or matching across multiple sources.

Learning Objectives:

  • The need for exchanging reliable clinical and administrative data in “real time” for better care coordination and population health management
  • How patient data is being exchanged securely and reliably for care coordination decisions
  • How HIE’s and health networks use quality health data to exchange and provide ‘actionable’ data insights in and out of their community

11:00 a.m. “Setting Utah’s Standards: You Hold the Power”
Boyd Kreeck | Business Analyst, UHIN

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The UHIN Standards Organization is a nonprofit, broad-based coalition of Utah healthcare insurers, providers, and others, including local government entities. The purpose of the Standards Committee is to develop administrative, technical, and billing standards and specifications based on existing federal and state regulation.

Standards created by the committee and approved by the UHIN Board are provided to the Utah State Department of Insurance, Utah Health and Human Services and published in State Rules and made available to the public at UHIN.org. In addition to developing Utah Standards, the UHIN Standards Committee participates in the development of National standards and guidance.

1:00 p.m. “The Present and Future of HIEs
Michelle Suitor | Director of the Clinical Health Information Exchange, UHIN

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A discussion on the history of interoperability and an overview of the various standards covered from both the claims and clinical standpoint. This session will explore what that means for Utah, and provide examples of specific use cases.

2 p.m. “Coordinating and Aligning Health IT: An update on nationwide health IT and interoperability goals”
Micky Tripathi, Ph.D., M.P.P. | National Coordinator for Health Information Technology, the U.S. Department of Health and Human Services

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Join ONC’s National Coordinator Micky Tripathi for updates on:

  • ONC’s work to align health IT activities across HHS agencies
  • How the Trusted Exchange Framework, Common Agreement (TEFCA) will ease information sharing across networks of EHRs and other health IT systems
  • The continued implementation and enforcement of the information blocking regulations
  • Data standardization efforts to promote equity, reduce disparities, and support public health data interoperability
  • And more!

3:00 p.m. “HIE Transformation: It’s About More Than Data
Mary-Sara Jones | Sr. Business Development Executive, Health & Human Services, Amazon Web Services (AWS)

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The Public Health landscape is changing. It is getting broader and deeper. The global pandemic highlighted fragmentation across and within organizations and the incompleteness of the data available to decision makers. There is a hunger for better, richer, cleaner data to support more holistic decisions and move efforts toward prevention. For many states data modernization and digital transformation will occur in parallel. Immediate updates to shared data infrastructure can provide meaningful insights while updated paradigms of service delivery are reimagined with modern technology to better meet provider and constituent expectations. Health Information Exchanges play a central role in creating and maintaining a connected data ecosystem driving improved patient outcomes and community vitality. This presentation with Natasha Nicolai explores future models for HIEs, how data transformation can provide immediate community impact, and what is required to create the parallel path to digital transformation.

3:00 p.m. “HIE Transformation: It’s About More Than Data
Natasha Nicolai | AWS WWPS SLG Leader, Health and Human Services Analytics, Amazon Web Services (AWS)

Read more

The Public Health landscape is changing. It is getting broader and deeper. The global pandemic highlighted fragmentation across and within organizations and the incompleteness of the data available to decision makers. There is a hunger for better, richer, cleaner data to support more holistic decisions and move efforts toward prevention. For many states data modernization and digital transformation will occur in parallel. Immediate updates to shared data infrastructure can provide meaningful insights while updated paradigms of service delivery are reimagined with modern technology to better meet provider and constituent expectations. Health Information Exchanges play a central role in creating and maintaining a connected data ecosystem driving improved patient outcomes and community vitality. This presentation with Mary-Sara Jones explores future models for HIEs, how data transformation can provide immediate community impact, and what is required to create the parallel path to digital transformation.

10:00 a.m. Beating Hypertension, the Silent Killer
Nickee Andjelic, MS, CHES | Maternal and Infant Health Program Manager, Utah Department of Health and Human Services

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The Utah 6|18 Workgroup is a cross-collaborative workgroup focusing on addressing 6 high-cost and preventable health conditions with 18 evidence-based and cost-effective interventions. For 2022, the workgroup selected to focus on self-monitoring blood pressure (SMBP) by hypertensive patients with clinical support to improve health outcomes and reduce healthcare costs. Hypertension is the silent killer and is a comorbidity and risk factor for a number of other chronic conditions. One in 4 Utah adults have diagnosed hypertension and 15-30% of Utah adults have undiagnosed hypertension. Strong evidence supports that SMBP interventions, when combined with additional support like patient counseling, education, or web-based support, are effective in improving blood pressure outcomes in patients with high blood pressure. Home blood pressure monitors are a covered benefit under Utah Medicaid and many resources are available to support clinic training and member education to encourage accurate SMBP and clinical support.

10:00 a.m. “Beating Hypertension, the Silent Killer
Dr. Richard Ferguson | Chief Medical Officer, Health Choice Utah

Read more

The Utah 6|18 Workgroup is a cross-collaborative workgroup focusing on addressing 6 high-cost and preventable health conditions with 18 evidence-based and cost-effective interventions. For 2022, the workgroup selected to focus on self-monitoring blood pressure (SMBP) by hypertensive patients with clinical support to improve health outcomes and reduce healthcare costs. Hypertension is the silent killer and is a comorbidity and risk factor for a number of other chronic conditions. One in 4 Utah adults have diagnosed hypertension and 15-30% of Utah adults have undiagnosed hypertension. Strong evidence supports that SMBP interventions, when combined with additional support like patient counseling, education, or web-based support, are effective in improving blood pressure outcomes in patients with high blood pressure. Home blood pressure monitors are a covered benefit under Utah Medicaid and many resources are available to support clinic training and member education to encourage accurate SMBP and clinical support.

10:00 a.m. Beating Hypertension, the Silent Killer
Rachel Vasquez | Quality Program Manager, Health Choice Utah

Read more

The Utah 6|18 Workgroup is a cross-collaborative workgroup focusing on addressing 6 high-cost and preventable health conditions with 18 evidence-based and cost-effective interventions. For 2022, the workgroup selected to focus on self-monitoring blood pressure (SMBP) by hypertensive patients with clinical support to improve health outcomes and reduce healthcare costs. Hypertension is the silent killer and is a comorbidity and risk factor for a number of other chronic conditions. One in 4 Utah adults have diagnosed hypertension and 15-30% of Utah adults have undiagnosed hypertension. Strong evidence supports that SMBP interventions, when combined with additional support like patient counseling, education, or web-based support, are effective in improving blood pressure outcomes in patients with high blood pressure. Home blood pressure monitors are a covered benefit under Utah Medicaid and many resources are available to support clinic training and member education to encourage accurate SMBP and clinical support.

11:00 a.m. The Challenge is HOW not Why: Integrating the Social Determinants of Health in Healthcare
Dr. Len Novilla | Associate Professor, BYU

1:00 p.m. “Countering Cybersecurity Risks Across Your Organization”
Keith Roberts | Information Security Analyst, UHIN

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Presentation on the importance of cybersecurity in healthcare. We’ll look at a recent data breach investigations report, how to stop cybersecurity, and the importance of staff training.

2:00 p.m. “Decentralized Identity and Verifiable Credentials in Health Care
George McEwan | Chief Strategy Officer (CSO), Department of Government Operations at the State of Utah

Read more

On May 26th, 2011 Google introduced Google Wallet on android phones. Not to be left out of a really good marking term, Apple followed suit on September 19th 2012, launching Apple Wallet. Ten years later and it is still “novel” to pay with a phone.  What happened and why does it matter now?

The future of legally binding, decentralized digital identity and verifiable credentials has expanded beyond simple digital wallets and is debuting in government in the near future. This session provides the background you’ll need to participate in the next identity revolution. 

3:00 p.m. Intro and Overview of the One Utah Health Collaborative
James Wissler | Executive Director, One Utah Health Collaborative

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This intro/overview of the One Utah Health Collaborative will have an emphasis on the barriers and the importance of community alignment regarding interoperability. A panel of innovators, clinicians, and interoperability experts will join Jaime Wissler to discuss the questions of how and why we’re working toward a longitudinal health record.

10:00 a.m. “Motivating for Performance: How Leaders Can Help Teams Find Their Drive”
Blake Bishop | Vice President of Data Services, Neovest, a JPMorgan Chase subsidiary

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Intrinsic motivation plays a pivotal role in organizational performance management. Not surprisingly, there is a strong correlation between employee motivation and business success. The factors that drive the desire to perform, however, may come as a surprise to many. In this presentation, we will explore what intrinsic motivation is, why intrinsic motivation matters, and how you as a leader can motivate your team members to perform at their peak.

11:00 a.m. “Medicare Hot Topics”
Lori Weber | Provider Relations Specialist, Noridian Healthcare Solutions

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This presentation encompasses updates, important topics and valuable resources to assist your practice with successful Medicare billing.

1:00 p.m. “Life of a Claim: Creation, Rejection, Elation”
Joy Cone | Application Support Analyst, UHIN

2:00 p.m. MYUHIN Claims
Greg Lobato | Group Product Manager, UHIN

Payer Panel

3:00 p.m. Payer Panel
Representatives from DMBA, EMI, HCU, Noridian Medicare B, PEHP, Regence, SelectHealth, and University of Utah Health Plans

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Q&A session with a panel of provider relations specialists and representatives from national and local, Utah health plans. This popular session answers some of providers most pressing questions. In previous years, questions have included:

  • Which are the most common errors that keep claims from processing?
  • What are the procedure codes with modifiers that should be used for phone visits for each insurance company?
  • Are all the payers reimbursing for Telehealth visits at the same rates as in person visits during the pandemic?

Sponsors

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Venue

Salt Lake Marriott Downtown at City Creek

75 S W Temple Street
Salt Lake City, UT 84101

Free parking for 2022 HIT Conference attendees

REFUND POLICY

We will accept refund requests up to 10 days following the date of the conference. To be eligible for a refund, you must submit via email to events@uhin.org. In your email, include your name, order number, and number of tickets to be refunded, as well as a reason for the refund request.

Once we receive your request, we will review and notify you on the status of your refund. If your request is approved, we will initiate a refund to your credit card or original method of payment.

Please contact events@uhin.org with any additional questions.