To manage DME billing, it is critical to understand its therapeutic use. Any member that requires benefits with equipment to certain conditions medically requiring repeated use is a DME. It has a definitive medical purpose.

Any ambulatory equipment, cane, crutch, CPAP and BIPAP machines, oxygen devices, monitoring devices and orthotics will fall under its ambit.
Also, respiratory devices, nebulizers and suction machines electric hospital beds, side rails, gel overlay mattresses, feeding equipment and products. It is evident that the segment is quite vast and requires effective planning if you are a DME provider!

Understanding DME Coverage & Billing

It is true that authorization varies from payer to payer. Copay or coinsurance is also a part of the entire coverage.
Understanding the benefits provisions that are a part of the member’s plan is an indispensable asset for better DME billing claims. It is mandatory to assess the general billing requirements.

Letter of medical necessity and the documents that are required for medical approval has to be streamlined for quick medical review. It is relevant for BIPAP machines, orthotics, mattresses and the beds.

Use of the correct modifiers that are appropriate has to be a part of DME. Considering the limitations that are based on an understanding of claims adjudication priorities of a payer is important.

A perfect instance will be the use of CPAP machines that cannot be ordered more than once within a period of 5 years!

However, one of the important aspects will be the segregation and how billing will replicate claims with the correct supplies in CPAP that complies to a specific time frame (3 months in most cases).

Also, it will be important to note that any maintenance, repair or replacement will be eligible under a separate reimbursement process with a maintenance fee that is contracted with a DME supplier acceptable to a payer.

The DME Billing Cycle

For transparency in DME billing cycle will be involving a lot of activities. Primarily it should start from the order based entry based on the Rx as determined by the physician.

Entry of the correct demographics with patient entry and insurance should be next step ahead. Correct entry of the provider history and the right product code is an extremely vital process.

The perfect Rx and the Dx entry that is based on the right intervals of time and timely eligibility verification complying to auth requirements will be laying down the right checks and balances.

Determining the Payer Criteria

After obtaining authorization, it will be pertinent to determine the criteria of the payer. Before the delivery of the equipment, it will be necessary to meet the specific mandates in relation to time, frequency and the annual cost limitations for consistency in insurance reimbursements.
Medical claims submission after generation of the delivery ticket will only happen after its receipt confirmation.

The EDI or paper submission will take the due course and quality rejection or denial management at this stage will be ensuring quick collections.
It requires an end to end revenue cycle management with a robust AR follow up process. A next-gen medical billing partner that serves as an extension to financial operations will do an excellent job.