DME Billing Prosthetics & Orthotics Billing

The Quick Guide to Orthotics and Prosthetics Billing Cycle Fundamentals

Orthotics and Prosthetics Billing CycleLike most healthcare specialties, billing for orthotics and prosthetic devices requires a very specific set of skills and expertise. Billing for such products is not a matter that can be taken lightly. With the stringent demands of Payers (health insurance plans) for accurate invoicing, even the slightest coding or billing errors can lead to claims getting denied, or even rejected!

Reaching the desired levels of efficiency in Orthotics & Prosthetics billing, however, can only be achieved if a streamlined and well-defined process is followed. In other words, one needs to perform all the tasks in the billing cycle with adequate care and diligence. So if you are even remotely concerned with Orthotics & Prosthetics billing, it is probably worth your time to familiarize yourself with the basics of this cycle.

Here’s a brief overview of the fundamental components that go into making up the entire Orthotics & Prosthetics billing cycle.

STEP 1: The billing cycle starts with order-entry based on the Rx received from the physician. It includes
a. Patient demographics & insurance data
b. Provider information
c. Product code

STEP 2: In some cases, the eligibility and authorization of the patient is verified, and the data is entered into the system. This step involves collecting all documents as required by the Payer for authorization approval, such as face-to-face consultation notes, Polysomnography / Titration report and so on.

STEP 3: In case of DME billing, a crucial step is determining that Payer criteria is met before delivery of the equipment in question. For example, some DME have time/frequency/annual cost limitations. If the criteria are not met, the patient needs to be contacted and informed of the financial responsibility.

STEP 4: In this step, a delivery ticket (on the basis of which delivery is made to the patient) is generated.

STEP 5: After receiving the delivery confirmation in the previous step, the claim is created and submitted to the concerned Payer

STEP 6: This is the cash posting phase. Over payments are immediately identified and necessary refund requests are generated for obtaining approvals. On the other hand, underpayments or denials are also informed to the Analysts for the next step.

STEP 7: While the formal billing cycle ends with the previous step, it may be extended further to include rejection / denial management and following up on pending accounts receivables.

A word of wisdom before signing off. With so much to take care of, most Orthotics & Prosthetics companies find it difficult to maintain efficiency in their billing processes, especially if they have an understaffed or inexperienced billing department. If you find yourself in a similar situation, try outsourcing your billing processes to a professional, dedicated billing company. It can work wonders in reducing denials, increasing cash flow and boosting overall profitability in your Orthotics & Prosthetics business.