DME – Durable Medical Equipment is normally used for people with certain medical requirements and which could be for repeated use too. Moreover, DME can also be used at different times and could be just rented out for specific periods or for long-term usage, or on a permanent basis. The complexities are many when it comes to billing for DME services, given the CPT codes and modifiers to be used and when. Added to this, some payers may or may not reimburse depending on their coverage or rules & regulations as each payer may have a different reimbursement component attached. Overbilling is one of the major issues that most medical providers of healthcare face when it comes to the DME billing process. This has led to the initiation of a number of audits by the OIG and can be a cumbersome affair.
Checklist to determine accurate DME billing
In order to determine if your facility has made provision for accurate billing transactions for DME orders, here is a checklist to work with.
- Modifier usage: Using appropriate modifiers and coding to the highest level of specificity requiring modifier use is very pertinent to accurate billing for proper reimbursements. Certified DME coders and billers are essential for any DME billing transactions given the complexity and details required to be known when coding for DME services
- Authorization: Today prior authorization costs are stated to stand at $31 billion annually. Authorization also varies from payer to payer. Further, Co-pay is also a part of the entire coverage. Understanding patient plans is very essential. Also, certain devices like the CPAP and BIPAP devices will need to be secured with pre-authorization, given that the $1000 mark will soon be abolished
- Verification & Eligibility: Order based entry based on Rx as determined by the physician and based on Dx wherein correct demographics of the patient and their insurance coverage is determined and verified- helps comply with the rules & regulations and also proper reimbursements ascertained
- Meeting specific Mandates: Before delivery of equipment, meeting all the required rules & regulations with respect to medical necessity and the time factor is very essential for the billing process and the claims submission which is dependent on the receipt confirmation and documentation
- Documentation: This is a critical component of the DME billing and claims process. There should be no variance between physician and nurse documentation that could lead to problems in coding for medical necessity. It is of critical importance that the letter of medical necessity and the documents required for medical approval should always be available on call.
Once your facility has the above-mentioned checklist points you will have reached some percentage of accuracy in your billing process. But keeping update with the rules & regulations and the intricacies involved when employing the appropriate modifiers and at the right time, is an art to be perfected, which cannot be done given our focus is the patient’s comfort and treatment. Hence, it goes without saying, that involving or outsourcing to a third-party vendor who is an expert in DME billing will help cut down the claim denials much more than what you have been so far experiencing and help cash flow into the RCM process once again!