Rejection and denials in DME billing impact reimbursement and cash-flows disrupting the Revenue Cycle Management process. Added to the denials, increased regulatory scrutiny is pushing most DME services to revamp their operations to streamline processes and enhance profitability too.
However, the need to question and analyze the reason why denials and rejections take place is essential for most DME billing services. Here is a checklist that can be employed to understand why denials are happening and reduce the denials making the claims process a smooth and profitable one.
- Verification and eligibility of Patient: Staff needs to check whether or not patient is insured and covered for DME services and what kind of DME services they are eligible for. No claims should be processed without rechecking this information. Even back checking of spellings of names, an information box checked wrongly, etc can lead to denial of the claim
- Coding and modifiers: If an invalid modifier or a required modifier is missing, the DME billing claim can be rejected. It is essential that a standard chart be updated every week so that if any changes brought in by any regulation can be immediately notified to the team of DME coders and billers. Appropriate codes and modifiers to support “medical necessity” for the DME product is essential
- Documentation: Appropriate documentation on file to support medical necessity for the DME product prescribed is very important not just for the coders and billers but also later if claim is rejected and /or during auditing, to justify the claim. For example a KX modifier is known to indicate that the provider has written the order and used to order the equipment/drugs/supplies needed to treat the patient. It is very vital that the order be kept on file by the supplier and made available to the carrier on request. This order needs to have the following: indicate the diagnosis/reason for the equipment/medication, the proper date, and the provider’s signature- without these the DME billing claim can be rejected/denied.
- Process & workflow: It is of utmost importance that you analyze and audit the internal processes and workflows. Streamlining these with stringent checks at critical points will help bring out the loopholes and problems. For example, besides a standard chart that is employed by coders, codes need to be updated and checked against new regulations and insurance policy providers.
In order to create sustainable and profitable DME billing process and workflow some operational changes would be the best way forward. New regulations and audits can drain not just your revenues but also slow down productivity. If you are into DME services then to help reduce denials focus should be on
- Transforming and redesigning your processes and organizational structure
- Upgrading and integrating essential technology platforms that will help streamline processes and also help analyze the pain points
- Outsourcing your end-to-end RCM to reduce denials in your DME billing and claim process