Pre-authorization requirements on CPAP devices have changed for Medicare Solutions and Connect plans, as reported by Network Bulletin of February 2016. Till now, the billed amount on the claim requires pre-authorization (or, to be precise, any CPAP/BiPAP claim which is over $1,000). Come May 1, 2016 and CPAP claims of all values will fall under the obligation of pre-authorization.
The signs are clear – a significant increase in pre-authorization for select DME equipment is anticipated. It is vital that all suppliers make suitable arrangements to address it in the best manner possible.

What does Pre-authorization mean?

It is a procedure through which a solicitation for temporary certification of scope is submitted for audit before a DMEPOS device is outfitted to a recipient and before a case is submitted for payment. Pre-authorization ensures that the applicable coverage, coding rules and payment are done before the services are released.

Advice for DME Billing Companies

One thing is certain, everybody involved in DME pre-authorization & billing is going to get very busy beginning in May of this year. CPAP and BiPAP devices are frighteningly common. And now, with the $1000 mark abolished, every device will need to be secured with pre-authorization.

In the face of this imminent surge in pre-authorization requirements, it is no wonder that a large number of DME companies have already started seeking out dedicated DME billers with sights on outsourcing all the extra pre-authorization jobs.

On a closer inspection, this surely looks like a good idea. In most cases, in-house billers fall miserably short, in terms of skill, experience or overall expertise, to handle stringent DME pre-authorization tasks efficiently. And with the added burden of more devices requiring authorization, the situation is likely to get out of hand in your DME billing department.

On the other hand, a professional, DME billing offsite staff can help your business to keep on moving, even in the face of mounting pre-authorization demands. The benefits add up – better management of accounts receivables, a smoother cash flow, more sales and happier customers are just a few of them.