Seven days into the Change Healthcare outage, the calls we get have changed. On day two the question was "are we affected". On day seven it is "why didn't we have a plan for this". Fair question. Almost every practice has a plan for the EHR going down: paper encounter forms in a drawer, a laminated sheet of phone numbers. Almost none has a plan for the clearinghouse going down, because until this month nobody thought it could stay down for more than an afternoon.
This article is the plan we wish every practice had on February 20. It is written for a practice with one to fifteen providers and a small billing team, and it is meant to be a document you actually write, not a concept. Every section ends with what goes on the page.
Key takeaways
- A claims contingency plan has six sections: the dependency map, a second submission route, eligibility and remittance fallbacks, the cash reserve, the daily held-claims count and the communication script.
- The core of the plan is a submission route that shares no point of failure with the primary one, enrolled and tested before you need it.
- ERA redirection is the step everyone forgets. Payments keep arriving; nothing posts; within two weeks the AR report is fiction.
- Hold six to eight weeks of operating expense, or a line of credit that covers the gap, and arrange it before the outage.
- One number runs the outage: completed claims not yet accepted by a payer, by date of service and payer, counted every morning.
Section 1: the dependency map
You cannot plan around a failure you cannot see. Most practices learned this month that their claims pass through two or three intermediaries between the practice management system and the payer, and that eligibility, remittance and patient statements may each take a different route. Ask your practice management vendor and your clearinghouse for the full path, in writing, for each transaction type.
| Transaction | Route (example) | Fallback if the route fails |
|---|---|---|
| Claims (837P) | PM system to clearinghouse A to Change Healthcare to payer | Direct payer portal upload; secondary clearinghouse; paper CMS-1500 for payers that accept it |
| Eligibility (270/271) | PM system real-time to Change Healthcare | Payer portals; Availity; MAC portal for Medicare; state Medicaid portal or IVR |
| Remittance (835) | Payer to Change Healthcare to PM system auto-post | Payer portal EOB download; manual posting from EFT and portal detail |
| Payment (EFT) | Payer to bank directly | Usually unaffected; confirm no payment processor sits in the middle |
| Claim status (276/277) | Clearinghouse polling | Payer portal or IVR |
| Patient statements | PM system to statement vendor | In-house print run; hold one cycle if the vendor is affected |
On the page: this table, filled in for your practice, with the vendor contact and account number for each hop.
Section 2: a second way to submit claims
The core of the plan is a submission route that does not share a point of failure with your primary one. There are three realistic options, and a good plan uses two of them.
Direct payer portals. Most large payers accept claims typed or uploaded through their own portal, and Medicare Administrative Contractors offer free claim entry software or a portal. This route needs no enrollment beyond a portal login, so it works on day one. It is slow, roughly two to four minutes per claim, which means it is a route for high-dollar and time-sensitive claims, not for volume.
A secondary clearinghouse. Having a second clearinghouse enrolled and tested in advance is the only way to move volume during an outage. The catch is that payer enrollment for electronic claims, and especially for ERA, has to be done per payer and takes weeks. The plan should identify a secondary clearinghouse, complete enrollment for Medicare, Medicaid and the top five commercial payers in advance, and send a small test batch quarterly. Yes, this costs a small monthly fee for a service you rarely use. Compare it with a month of no cash.
Paper. Some payers still accept CMS-1500 forms. Medicare requires an approved waiver for paper submission, which MACs can grant in situations like this one. Paper is a last resort for a defined list of payers, and the plan should name them.
On the page: the secondary route for each of your top ten payers, whether enrollment is complete, and the date of the last test.
Section 3: eligibility and remittance without the clearinghouse
Eligibility falls back to payer portals, and the plan should list the portal, the login owner and the average time per check for each of the top ten payers. Prioritize by dollar value at risk: a $4,000 procedure gets checked by phone if necessary; a $95 follow-up may proceed on the card copy and last month's eligibility.
Remittance is the piece practices forget. When the 835 stops, payments still arrive by EFT, but nothing posts. Within two weeks the AR report is fiction. The plan should say who downloads EOB detail from payer portals, in what order, and how manual posting is checked against bank deposits. Expect a posting backlog and plan overtime for it. A practice posting 150 claims a day electronically will need roughly one extra full-time person to post the same volume by hand from portal EOBs, so the plan should name who that is and what they stop doing.
Section 4: the cash reserve and the credit line
An independent practice typically collects most of a month's revenue 20 to 45 days after the visit. A clearinghouse outage does not stop visits, but it delays that whole curve. The plan should state the practice's monthly fixed cost, the cash on hand in weeks of operating expense, and the credit facility available. We think practices should hold at least six to eight weeks of operating expense or have a line of credit that closes the gap. Arrange the line before you need it; banks are slower when you are already in trouble.
Worked example. A five-provider practice has monthly operating expense of $320,000, of which $210,000 is payroll and payroll taxes. It has $400,000 in operating cash, which is about 5.4 weeks. If 70 percent of its claims route through the failed connection and the outage lasts four weeks, roughly $450,000 of expected collections shifts to the right. The practice runs out of cash in week six unless it draws on a line, delays vendor payments or finds an advance. Writing this down in February, with the real numbers, is the difference between a phone call to the bank and a missed payroll.
Section 5: the daily count
During an outage, one number matters more than any other: claims completed but not accepted by a payer, by date of service and by payer. Run it every morning. Sort by the oldest date of service. Match each payer against its timely filing limit. Anything within 30 days of a filing limit moves to the direct portal route that day, regardless of dollar value. Report the count to the practice owner daily. When the outage ends, this list is the release order.
On the page: the report name or query that produces the count, who runs it, and the timely filing limit for each of your top ten payers.
Section 6: communication
Staff need a one-page script for patients asking about pharmacy problems, bills that have not arrived, or eligibility they were told was verified. Providers need to know that documentation and charge capture continue exactly as before. Vendors need a single point of contact in the practice, and the practice needs a single status page to check, not five email threads. On the page: names, numbers, and the script.
The test
A plan that has never been run is a guess. Once a quarter, on a quiet Friday afternoon, pretend the primary clearinghouse is down: send five real claims through the secondary route, check eligibility for tomorrow's first ten patients through portals, and post one payer's remittance by hand from the portal. Time each step, write the times on the plan, and fix whatever broke. The whole drill takes about two hours. Most practices discover on the first drill that a portal password has expired, a payer ID is wrong or the secondary clearinghouse enrollment lapsed. Better to find out in a drill.
Questions we hear
Is a secondary clearinghouse really worth paying for?
Before this month we would have said it depends on the size of the practice. After this month our view is that any practice with more than two providers should have one enrolled for at least Medicare and its top payers. The cost is small next to a month of delayed cash.
Our practice management system only works with one clearinghouse. What then?
Then your secondary route is direct payer portals and the MAC's free claim entry tool, and your plan should say so honestly. Enroll for portal access with every payer that offers claim entry, keep the logins current, and accept that volume will be slow. Raise the single-clearinghouse limitation with the PM vendor at renewal; it is a fair negotiating point after this month.
What happens to claims that miss timely filing because of the outage?
Some payers will grant extensions, and several have already said so; keep your outage log as evidence. Do not count on it. Move at-risk claims to a working route now. The Revelrex RCM audit includes a business continuity review of exactly these six sections, and we run the held-claims count every morning for the practices on Revelrex billing.
What to do this month
- Fill in the dependency table with your vendors this week, while the outage makes them responsive.
- Pull the held-claims count by date of service and payer today, and start the daily rhythm.
- Pick a secondary clearinghouse and start Medicare EDI enrollment, even if you hope not to use it.
- Download EOBs from your top three payer portals and start manual posting before the backlog grows.
- Write the cash section with real numbers: monthly operating expense, weeks of cash on hand, and the line of credit you have or need. Then talk to your bank.
- Put the first quarterly drill on the calendar for a Friday in May, after the outage has ended.
