On February 21, 2024, Change Healthcare took its systems offline after a cyberattack, and for weeks a large share of the claims in the United States had nowhere to go. Practices that had only ever known one route to their payers discovered that switching clearinghouses takes weeks of enrollment paperwork, that payer portals require logins nobody had set up, and that a practice with a month of unpaid claims runs out of cash faster than anyone expected.
Two and a half years later, most practices we talk to still have exactly one route to their payers and no written plan for what happens when it stops. The clearinghouse is a single point of failure that sits between every claim and every dollar. Treating it as infrastructure that will always be there is a decision, and it is the wrong one.
This is the contingency plan we ask practices to keep. None of it is expensive. Most of it is a spreadsheet, a few enrollments and an afternoon of testing.
Key takeaways
- Build the payer route list now: for each top payer, the clearinghouse payer ID, the portal, the paper address, and how ERAs and EFTs arrive. It is the first thing you need in an outage and takes two hours when nothing is wrong.
- A secondary clearinghouse enrolled in a quiet month can be switched to in a day. One opened during an outage joins a queue of thousands.
- Remittances do not follow claims. Know how ERA enrollment is changed for each payer, and keep EFT pointed at your bank, not an intermediary.
- Get written answers from your practice management vendor: can you export 837 files, and do you hold copies of every 837, 835 and 277 outside the clearinghouse?
- Know your cash position in weeks and have a six-week plan. Then test the backup route once a year.
Know your routes
Start with a payer list that shows, for each of your top twenty payers by volume: the payer ID at your current clearinghouse, whether the payer accepts claims through its own portal, whether it accepts paper CMS-1500 claims and at what address, and whether you receive ERAs and EFTs from it and through which channel. Most practices cannot produce this list. It is the first thing you will need in an outage, and it takes two hours to build when nothing is wrong.
Add two columns most practices skip: the portal administrator's name and the date the account was last used. A portal nobody has logged into for a year is locked, and a locked account on the first day of an outage is a two-day delay while the payer verifies who you are. Assign one person to log into every low-use portal on the first business day of each month; the same habit that keeps portal access healthy keeps the fallback route open.
The four fallbacks, in the order to use them
| Fallback | Lead time if not prepared | Lead time if prepared | Good for |
|---|---|---|---|
| Direct payer portal submission | Days to weeks to set up accounts | Same day | Medicare (through the MAC portal), large commercial payers, Medicaid |
| Secondary clearinghouse | Two to eight weeks for EDI enrollment, longer for some Medicaid programs | Same day to a few days to re-point the PM system | All electronic payers at volume |
| Paper claims | Same day, but slow payment and higher rejection rates | Same day | Low-volume payers; the last resort |
| Payer-specific direct EDI connections | Weeks | Same day | The one or two payers that are most of your revenue |
The lesson from 2024 is the middle column. Everything is possible without preparation; almost nothing is fast. Payer EDI enrollment forms for Medicare, Medicaid and many commercial plans must be submitted per clearinghouse, and the payer processes them in its own time. A secondary clearinghouse account that was opened and enrolled in a quiet month can be switched to in a day. One that is opened during an outage joins a queue of thousands of other practices doing the same thing.
Enroll the secondary clearinghouse for your top ten payers only. That covers most of the revenue, keeps the enrollment work to a few afternoons, and leaves the long tail of small payers to portals and paper. Medicare and the state Medicaid program go first, because their EDI enrollment is the slowest and they are usually the largest share of claims for the practices that were hurt most in 2024.
ERA and EFT: the part everyone forgets
Claims are half the problem. Remittances are the other half. When you route claims through a different clearinghouse, the electronic remittance advice does not automatically follow, because the payer sends the 835 to the clearinghouse named on its ERA enrollment. During an outage, practices found their claims going out through a new route and their remittances still trying to arrive through the old one. Payment posting stopped, patient balances could not be calculated, and secondary claims could not be released.
The fix is to know, for each payer, how ERA enrollment is changed and how long it takes, and to keep EFT enrollment pointed at your bank rather than at any intermediary. Keep a copy of every ERA and EFT enrollment form you have ever submitted. In a pinch, most payers will let you download remittances from their portals, which is slow but works. Some clearinghouses can receive ERAs for a payer even when claims go elsewhere, so ask your backup whether it can be enrolled for remittances only; that halves the work of switching.
The data you must be able to reach
Ask your practice management vendor two questions in writing. First: if the clearinghouse is unavailable, can we generate 837P files and submit them elsewhere, and how? Second: do we have a copy of every 837 we have sent and every 835 and 277 we have received, stored where we can reach it without the clearinghouse? If the answer to the second question is no, you cannot prove timely filing after an outage, and you cannot rebuild what was in flight when the connection dropped. Practices that route billing through a partner should ask the partner the same questions; Revelrex's billing service maintains alternate clearinghouse connections for exactly this reason, and we think any billing company should be able to describe its plan in a page.
Timely filing is the quiet casualty of an outage. In 2024, many payers extended filing limits for affected providers, but each did it on its own terms and some required proof that claims had been submitted before the outage. A practice that could produce the 999 and 277CA acknowledgements for its February batches could argue the point; a practice whose only copy lived at the clearinghouse could not. Download and keep the acknowledgement files, not just the remittances.
The cash plan
In 2024 CMS set up a program of accelerated and advance payments for Part B providers affected by the disruption, and some payers offered advances. Neither is something to count on. A practice should know its cash position in weeks of operating expense and have a plan for a six-week gap in insurance payments: a line of credit arranged in advance, a conversation with the bank, and a clear list of which expenses can be deferred. During the outage, some practices kept cash flowing by collecting patient balances aggressively and sending paper claims to their largest payer. Those were the practices that had the payer list.
Put a number on it. A practice that collects $300,000 a month from insurers and holds $250,000 in operating cash has about five weeks before payroll is at risk if claims stop; add patient collections and the deferrable expenses and the figure moves. The owner should know that number today, not learn it in week three of an outage.
Test it once a year
A plan that has never been tested is a hope. Once a year, pick a quiet week and send one day's claims for one payer through the backup route. Confirm they were accepted, confirm the remittance arrived, and note what broke. It will take an afternoon, and the next real outage will take a day instead of a month. Write the test date and the results on the plan, and fix what broke before the next one.
Questions we hear
Isn't a second clearinghouse expensive?
Many clearinghouses charge little or nothing for a low-volume account, and the enrollment work is the real cost. Compare it with the cost of a month with no claims going out. For most practices it is not a close decision.
Our EHR vendor bundles the clearinghouse. Can we still have a backup?
Usually, but you need to know whether the system can export 837 files and accept 835 files from a different source. Some cannot without vendor help. Find out now, in writing, rather than during an outage when the vendor's support queue is also full.
Who owns this plan?
The practice manager or the billing lead, with a named backup, reviewed every October. Keep the payer list, the portal logins (in a password manager, not the spreadsheet), the enrollment forms and the vendor answers in one place, and make sure two people know where it is. If your practice wants an outside review of its billing technology and its single points of failure, our RCM audit includes this check.
What to do this month
- Build the payer route list for your top twenty payers, with portal administrators and last-login dates.
- Send the two questions to your practice management vendor in writing and file the answers with the plan.
- Open a secondary clearinghouse account and start EDI enrollment for Medicare, Medicaid and your eight largest commercial payers.
- Collect every ERA and EFT enrollment form ever submitted into one folder, and confirm EFT points at the practice's bank.
- Calculate weeks of operating cash and talk to the bank about a line of credit before you need one.
- Put the annual backup-route test on the calendar for a quiet week in the first quarter.
