Is DME billing giving you nightmares?

Durable Medical Equipment, as the name implies is medical equipment that is necessary for patients over a period for supportive medical care.DME Billing is a complicated process that involves patient validation, getting prior authorizations for DMEs exceeding the allowed limit if rented or purchased, using correct forms for claims submission (electronic or paper), submit claims to the primary insurer if there is one, ensuring to submit the itemized bill with the claim form, usage of HIPAA compliant billing software, determining the proper billing codes (CPT, HCPCS, ICD-10 CM), resubmitting denied claims with the correct codes. All these can be very exhausting and prone to errors and delay in claim settlements and in some cases, recoupment of claims also happens.

Moreover, increased regulatory changes & scrutiny, & the emergence of competitive bidding have impacted reimbursement. Physicians involved in providing DME services are facing the brunt which is affecting operations and profitability and the nightmare of how to deploy resources and where to invest.

When a patient gets a prescription for a DME, the provider needs to verify the patient’s (beneficiary) eligibility and valid coverages under their benefits plan. Most of the cases the DME supplier or the beneficiary’s medical care provider needs to file the claim for the DME services and supplies being purchased. There are limitations to the time when the claims need to be submitted. The provider needs to process the patient’s payment forms, correctly mention if the DME is required for treating a work-related injury, and several other facts that make the claim filing process very complicated. Claims need to be accurately filed to minimize rejections and denials.

DME claims are also ever-increasingly being subjected to audits by the insurer to reduce claims where there is not strong medical justification, insufficient or incorrect documentation, and incorrect codes being used.

As practices and suppliers find this not wanting, medical billing experts come into the picture to streamline such tedious processes. They help in ensuring documentation meets policy standards using advanced billing systems, ensure compliance, bring awareness of services being reviewed by the OIG/audit bodies, ensure minimal claims rejection/recoupments.

Medical practices and all medical care providers are bound by complex federal and state rules and regulations. Healthcare is also one of the most regulated industries in the United States. According to the American Hospital Association, last year the federal government added 23,531 pages to the regulations affecting hospitals and health systems. Do all these pose one question paperwork or patient care?

There are many ways to ease the stress of billing for DME, realign the workflows and processes in the house after studying where the gaps occur, and invest in infrastructure and certified coders & billers. Regular internal audits will soon help identify problems to enable a more efficient and effective claims process.

Besides, in-house, you can also outsource not all, but also just the claims management process and integrate with your own processes within seamlessly to reduce claim denials.

When automation of some of the processes is introduced, and expertise in the coding & billing process is implemented, it helps take away some of the tension. Besides, implementing stringent documentation and an efficient front desk office team that can verify the eligibility of the patient payer’s insurance coverage will definitely reap profitability and make the Revenue Cycle Management system much more profitable and effective.

Besides these regular kinds of problems being faced another major problem that could put those dealing in DME services at risk is the soliciting & selling via telemarketing of DME products to seniors. This is causing the practice to contribute to the estimated $60 billion in fraudulent Medicare payments each year. Such unethical practices are thus posing a risky problem for those healthcare providers dealing with DME services and making them a target for increasing regulatory audits.

Ensuring documentation is right as soon as the patient steps in, and keeping on the right side of the law, will help lessen the tension and help you sleep well at night!