The billing process of durable medical equipment involves intricacy. Due to the continuous changes in the billing process, it has also become laborious and time-consuming. This is why you need to adhere to a durable medical equipment billing guide to comply with the regulations and comprehend the nuances.
Oftentimes, DME providers face numerous billing issues, which eventually result in poor reimbursement rates and a significant loss in revenue generation.
What is DME Claims?
DME claims refer to claims submitted for reimbursement of durable medical equipment (DME) prescribed by a healthcare provider. DME is equipment that is used to treat a medical condition, illness, or injury and is designed for repeated use. Examples of DME include oxygen equipment, wheelchairs, hospital beds, crutches, and prosthetic devices. The reimbursement process for DME claims involves submitting the necessary documentation to the patient’s insurance provider, including a prescription from a healthcare provider, and a detailed invoice from the supplier. The insurance provider will then evaluate the claim and reimburse the patient or supplier for the cost of the equipment, according to the terms of the patient’s insurance policy.
In order to prevent this reimbursement from errs and a lower revenue rate, follow this simple yet effective durable medical equipment billing guide to ace the process.
Step by step process of filing DME claims
Step 1: Get the necessary documents
For obtaining the accurate billing results, you need to review and secure the following documents;
- Medical prescriptions – An official order from a health care provider that indicated the needs of DME for the treatment of the patient. For example; if a patient is diagnosed with a sleep apnea disorder, he possibly recommended CPAP therapy which is given by the CPAP machine.
- Prior authorization – Prior to issuing the order, a healthcare provider must determine if the patient has the approval of having DME from Medicare. This is because the Centers of Medicare and Medicaid Services (CMS) made it a prerequisite in May 2014 to authorize such DME needs for a later DME claim. This also applies to the machines involved in CPAP therapies. This need is targeted to make sure that CMS will not pay for the machine and equipment that are not necessarily required medically.
- Certificate of medical necessity – a medically approved form that shows the medical need along with the requirement of a DME, which will be used to prevent certain diseases. Also, it must be filled by the patient’s physician and signed by both physician and the DME provider.
- Proof of delivery – Prior to COVID-19, a signed delivery slip was only required to prove the DME claims delivery. But to prevent the spread of the virus, CMS waived this requirement in March 2020. Afterward, a photo of the recipient and the DME is accepted as proof of delivery.
Step 2: Verifying the eligibility of patient insurance
In the next step, a DME provider confirms the information and details from the insurance company that the patient provided while filling out the DME form. The information includes the coverage in the patient’s insurance, and the type of insurance he or she has. Other information that might be needed includes the insurance group plan and the policy number.
Step 3: Generate the invoice
Once the necessary authorization has been taken and verified, the DME provider can make an invoice. The invoice should be properly processed making sure that every DME code is efficiently added according to the latest guidelines provided by the HCPCS (Healthcare Common Procedure Coding System). When it comes to CPAP machines from the DME provider, the invoice will be processed not only for the CPAP machine but everything that comes with it like mask and tube, etc.
Step 4: Filing the claim
According to the ASCA (Administrative Simplification Compliance Act), Medicare claims should be filed and submitted electronically. Although, if a DME provider meets certain requirements like less than ten working employees, then they can submit the claims through a CMS-1500 paper. Once the claims are submitted either electronically or through CMS-1500 are monitored by Medicare Administrative Contractor (MAC). This process can take no longer than thirty days to be completed.
Other than Medicare and Medicaid, private insurance companies also require medical practitioners to claim reimbursements electronically. For this, DME officials can file their claims directly on the website portal of the insurance provider, or in the case of paper claims, they can be converted into a standard format required at the time of submission.
Step 5: Resubmission of claims
In case of reimbursement rejections, DME providers can resubmit the claims once the required documents are attached and the necessary amendments are made. However, if the claim satiates all the requirements and the invoice is processed accurately, the claims are likely approved and payments are released within a few weeks of submitting the claims.
To avoid rejection and the long process of submitting the claims, it is necessary to follow a durable medical equipment billing guide. Follow these steps to make sure that your claims get approved timely without creating revenue glitches.