It is a known fact that in the RCM process every process and workflow in the medical billing cycle has a correlation with the revenue cycle function. This is known to contribute to an industry average of 15–25 percent of overall operating costs ( a large population of DME/HME companies continues to operate at 25–35 percent revenue cycle costs). Added to this, is the increasing complexity of insurance benefits that DME billers have to deal with.
And further adding to the woes are regulatory audits! Audits have led to increased scrutiny of processes, and appeals have grown more than 150 percent over the last three years as a result of high claim rejections. Moreover, due to the swing on pricing and sales strategies and other factors, DME Billing Suppliers work with slim margins, competitive bidding, and often than not unfavorable contracts dictated by the payers.
So what are the main points that DME Billing Suppliers need to look for if they intend to enhance their RCM, specifically from Insurance payments?
Below is a basic checklist to begin with and get you started in order to stabilize your RCM
Documentation of the patient’s medical record:
It is of utmost importance that a copy of the patient’s visit is created that documents the need for the equipment. This then needs to be supplied to the DME provider along with the signed order
The Face-to-face encounter:
The physician must document that he/she, PA, NP, or clinical nurse specialist (CNS) has had a face-to-face encounter with the beneficiary within six (6) months prior to completing the detailed written order. And when a DME supply is ordered by a PA, NP, or CNS, an MD or DO needs to verify that a face-to-face encounter occurred by signing or co-signing the pertinent portion of the progress note that indicates there was a face-to-face encounter. Only in certain situations can an NP or CNS give the dispensing order and sign the detailed written order and only if certain requirements are met can the PAs provide the dispensing order and write and sign the detailed written order
Medicare will deny Durable Medical Equipment, Prosthetic, Orthotic, and Supplies (DMEPOS) claims if the ordering/referring physician is not identified, not enrolled in Provider Enrollment, Chain, and Ownership System (PECOS), or not of a specialty type that may order/refer the service/item being billed. DME supplier must meet eligibility and/or credentialing requirements to be eligible for reimbursement from the payer
This is often being used anywhere between 38 to 64 percent of the time, depending on the specialty. This then gives a clear indication of why payers think that patients are not really sick and hence don’t wish to increase their fee schedules. Using of unspecified code does not really explicitly give details to support the severity of the patient’s condition. Continuing to improve documentation will help providers support the quality, severity, and risk involved with patient care.
Understanding Payer/Product rules:
Patients come with different payer products. It is essential that verification and eligibility of patient and payer rules are thoroughly checked and required documentation is produced to avoid complete or partial denials
These are some of the Checkpoints that every DME Billing Supplier should follow in order to enhance their RCM from Insurance payments