DME Billing Claims: Essential Insights and Updates

With the growing prevalence of chronic conditions like COPD, diabetes, and arthritis, more patients need access to DME. Unfortunately, some of the devices can be costly and insurance coverage is quite critical. A reliable DME billing solution ensures the consistent accessibility of the medical apparatus to the patients while ensuring the enhanced financial health of the practice.

From technological advancements to appropriate DME billing solutions, this blog covers the critical nuances of navigating complex DME billing and coding.

DME Billing Claims in a Nutshell

Generally, billing DME claims involves submitting documents to insurance providers to reimburse medical equipment and training for equipment provided to the patients.

The DME billing process encompasses several key steps, each of which is vital for ensuring accurate and timely reimbursements as well as compliance with regulations. Gathering necessary patient data from the referring healthcare provider, like coverage, demographic details, and prescription details is the primary step of DME billing. This information is crucial for developing a comprehensive and accurate claim.

Following the collection of patient data, the next step is insurance coverage verification for the specific DME item. This step ensures that the patient’s insurance plan covers prescribed equipment and understands prior authorization requirements and limitations.

Once the eligibility is confirmed, you must submit a claim to the insurance company for necessary reimbursements. The claim includes details such as the patient’s diagnosis, procedures performed on the patient, prescribed equipment, service dates, and the cost of the equipment. In this stage, you must ensure proper coding of the equipment (HCPCS and CPT) and services (typically, training for using the DME) provided.

Following the submission, the insurer reviews the credibility and authenticity of the claim, and based on the information provided the claim is either rejected or the services are reimbursed.

In case of claim denial, you need to file an appeal, delivering more evidence or clarification to support the claims.

Essential DME Billing Insights and Updates

The landscape of DME billing efficiency is being significantly influenced by the dynamic interplay of technological advancements, rising costs, and a shift towards patient-centric care.

1. Customizable DME: 3D printing technology has enhanced the creation of customized DME, such as orthotics, tailored to individual patient needs. As newer technology is gaining momentum, 3D printing is poised to impact the cost and time required to produce durable medical equipment, making customized DME affordable for patients.
2. Rising costs: Studies have suggested that the changes in competitive bidding by CMS have garnered over $3 billion in savings from vendors competing on DME products. The changes within the policies can be challenging for the providers to cope with the changes within the DME billing processes.
3. Streamlined prior authorization: The American Medical Association has been advocating fixing prior authorization and focusing on patient-centered care. The reforms are focusing on confirming a diagnosis and procedure as soon as possible to reduce the delays in care.
4. Transition period for new enrollees: When a patient changes Medicare Advantage (MA) plans while receiving treatment, the new plan has to offer a minimum of a ninety-day transition period when continuing therapy cannot be denied without prior authorization. This guarantees a seamless transition of care throughout the treatment.
5. Data analytics in billing: Advanced technology is transforming every segment of the industry and DME billing is no exception. To analyze the current performance of the practice, most of the providers are focusing on the implementation of data analytics within the billing process. This ensures the analysis of the current financial situation of the practice and helps to develop a strategic approach within the billing process.

Takeaway

To effectively anticipate and handle DME billing difficulties, stay up to date on the most recent billing insights. Compliance, stable finances, and efficient patient care can all be guaranteed by keeping track of billing claims, clinics, and billing specialists. This proactive approach aids in efficiently organizing billing activities, including prior authorization, with outsourcing partners.

Tap into Our Expertise

Avoid being hindered by obsolete DME billing procedures. At Sunknowledge, we provide you with a holistic approach to your billing and coding services. For more than a decade, our expert medical billers and coders have been providing streamlined solutions to some of the biggest DME players within the country. Our experts undergo frequent training to stay updated on the latest technology, policy revisions, and fluctuations in equipment prices. From data management and prior authorization to claim submission and denial management, we can streamline your pre- and post-billing services at just $7 per hour.

Be assured that our services are tailored to accommodate all your requirements for managing DME billing and coding and guarantee optimized revenue generation. The only healthcare revenue cycle management organization serving both payers and providers is here to transform your practice operations. You can contact one of our experts to understand why we are hailed as the best in the industry.