Durable Medical Equipment billing is complex as it requires a detailed understanding of how to code claims, what to bill for, and when to submit claims. Recently, there have been several cases of incorrect DME billing process, either due to a lack of knowledge or a fraudulent attempt to make money. DME billing fraud comes in a variety of shades and colors.
Billing for items that were not ordered or received is a common type of fraud. The discrepancy is revealed in the paperwork known as the Explanation of Benefits (EOB) or Medicare Summary Notice (MSN). Sometimes fraud occurs when a patient receives equipment not prescribed by the doctor.
Other types of fraud include receiving a phone call from someone unrelated to the physician’s office requesting Medicare information, billing for duplicate orders, higher-than-normal rental charges for equipment, etc. Insurance companies detect fudged billing with great expertise, regardless of how it is committed. However, they can result in heavy fines. That’s why it is essential to look for successful ways to deal with it at the earliest, along with the exact submission process.
DME Claims Submission Procedure
The steps are as follows:
- A provider determines the DME needs of a patient to provide specialized care.
- The provider thoroughly documents the medical necessity.
- Prior authorization is obtained from the provider’s medical billing company to get DME supplies.
- It is always a good idea to have an advanced beneficiary notice, or ABN, in place so that if the equipment is not paid for, the patient is liable for the amount.
- Following prior authorization approval, the patient collects the DME from the DME supplier.
- The medical billing company assigns the appropriate HCPCS Level II codes to the DME claim and submits it to the payor.
- To ensure accurate payment posting, the accounts receivables management team follows up on the claim.
DME Billing Guidelines
Apart from the DME claims submission process, you should be aware of the DME medical billing guidelines, which are as follows:
- A DME is to be used repeatedly over three years and serves a specific medical purpose.
- DME billing should not include consumable or disposable items unless they are absolutely necessary for the DME to function correctly.
- It can only be done for medically necessary equipment.
- A prescription must be issued to the patient.
- Prior authorization from the payer is required for DME billing by the medical practice.
- DME coverage benefits are typically for a DME that meets the patient’s minimum specifications.
- DME medical billing is also typically not possible for accessories added for the patient’s comfort or convenience, such as air purifiers or humidifiers.
- Medicare will only pay DME claims if the ordering physician and DME supplier are active Medicare members on the service date.
Ways to Streamline DME Billing
Streamlining the DME billing process can significantly improve reimbursements. This entails putting in place the necessary checks and balances. It also entails having a consistent prior authorization process and a thorough accounts receivable process. Other ways include:
- Ensure proper documentation
Only when the claims are submitted correctly can your DME billing be correct. For example, if the HCPCS code ends in “99,” you must provide the necessary supporting documentation to receive the claim. The insurance company will suspend the claim if these are not provided. This can cause unnecessary delays. Even in this case, calling the provider for confirmation is beneficial. It allows you to stay updated on the most recent changes in provider requirements and adhere to them.
- Adequate Prior-Authorization Procedure
A thorough eligibility verification and authorization process can significantly simplify DME reimbursements. The best way to ensure this is to implement prior-authorization technology. Integrating your electronic prior authorization tool with your EMR is preferable. Prior approvals will be upgraded and expedited proactively. This allows for greater control over denial management.
- A Robust Accounts Receivable Process
Managing current and aging DME billing accounts necessitates a delicate balance. You must provide your team with the most advanced DME billing software to obtain this balance. Critical metrics, such as complete and accurate filing, must drive the process. Similarly, you must train your team to understand the payer’s requirements. This greatly simplifies the recovery of aging accounts.
Outsource your DME Billing
Outsourcing is the most effective way to improve your DME billing processes while decreasing collection time. Here are a few examples of how working with 24/7 Medical Billing Services can help your company:
- Understands the healthcare system in the United States
- Reduces your DSO (day sales outstanding)
- Lowers your overall operating costs
- Increases the size of your billing department without the hassle of hiring new employees
- Finds ways to increase claim and patient collection rates
- Continuous education on industry regulations is provided
Are you ready to improve your DME billing processes and collection rates while saving time and money? Then contact 24/7 Medical Billing Services to find out how we can help you get the most money out of each claim!