It is well known to physicians that durable medical equipment (DME) services are ancillary to the primary clinical purpose. However, most physicians are also aware that when prescribing DME, they may not get the reimbursement due to them as their admissibility is subject to certain conditions. There may be a number of reasons for why physicians who prescribe DME to their patients, their claims are often denied or rejected. The reasons could be due to:
- Deemed medically unnecessary
- They did not have the proper credentials and thus deemed Uncertified by Medicare/Medicaid/private health insurers
- They have claimed beyond the permissible reimbursement level
- Have not met certain regulations & compliances set down by the Healthcare Common Procedure Coding System (HCPCS)
One of the major setbacks faced by physicians is the lack of drive to back their recommendation with sufficient proof of the service rendered being medical necessary. And this is due to bad processes in verification & documentation, which leads to low resubmission for claims and thus losing a lot of reimbursements affecting their Revenue Cycle Management (RCM) process. Moreover, in 2015, Medicare had a 40 percent improper payment rate for durable medical equipment, prosthetics, orthotics and supplies, resulting in $3.2 billion losses.
Here are some simple ways where physicians can overcome the initial steps at least:
- Verification & eligibility: Be it the front office or the physician himself, the patients insurance coverage should be verified and deemed eligible for DME services
- Vendor admissible DMEs: Physicians are well advised to also check that when sourcing DMEs for patients, they are from payer-recognized vendors or manufacturers only as reimbursements are subject to that condition. Physicians should be aware that Medicare has designated pharmacies that supply admissible DMEs.
- Documentation: Insufficient documentation is the most common DMEPOS billing error and accounted for $2.6 billion in Medicare losses. Documentation is very essential for backing “medical necessity” the most vital criteria when physician’s prescribe for DME, and for this documentation of the patient’s history and diagnosis and treatment required is crucial. This also provides the coders and billers an easier way to crosscheck during the claims process.
- Coding & Billing: with the new ICD-10 coding and change in certain modifiers- wrong codes, absence of modifiers and insufficient narration can also contribute to claim denials & rejections leading to drastic falls in reimbursements due to insufficient knowledge of DME billing
- Compliance: The increasing number of different kinds of audits by the OIG and healthcare departments are leading to more operational work rather than clinical work and thus putting pressure on the already burdened staff. Automation and streamlining your systems and workflows is of utmost importance to avoid being investigated for either being overpaid or not conducting your services as per the rules and regulations prescribed by the Healthcare Departments
For most of the above, especially the crucial claims process, outsourcing your claims process could be a good idea. Medical Billers and Coders (MBC) have the experience of handling and negotiating DME claims. The trained and knowledgeable staff are updated with state-specific Medicaid policies, Medicare, and a host of private health plans. MBC is noted for its operational excellence. This inevitably drives positive and enhanced clinical outcomes providing for an efficient Revenue Cycle Management (RCM) process, which provides for better income for the in-house staff to deliver positively on the clinical front.