If you provide durable medical equipment, you know your routine very well: You provide the equipment, you get the claim submitted, and then you wait, sometimes weeks, for the claim to be denied for an almost inconsequential reason. A missing modifier. An expired authorization. A code which is not exactly documented.

It’s agony and bank-busting! The delay of pay means lost cash flow, additional hours with personnel researching claims, and sometimes lost revenue. That’s why many suppliers are opting for specialized DME billing services rather than operating in-house.

Let’s take some time to understand why DME claims fail frequently and how professional DME billing companies are able to overcome this while also ensuring that you get paid sooner.

Why DME Claims Get Denied So Often

The billing process is unique for durable medical equipment and is a much harder process than medical billing. Denial of a single claim may be associated with rigid documentation requirements, prior authorization procedures and coding minutia, specific to each payor, and leave any one of these items up for grabs for a denial.

Common DME Billing Errors and Solutions

Some of the most frequent culprits behind denied claims include:

• HCPCS codes for billing DME and modifiers are subject to change, and if you use an outdated code, it’s a simple mistake to make and will get you flagged.
• Payer prior authorization billing must occur before, not after, DME is dispensed (many payers require).
• Insufficient medical necessity documentation Payers want clear physician justification, not vague notes.
• Incomplete supplier compliance records DME supplier billing compliance issues, like lapsed accreditation, can stall claims entirely.
• Diagnosis or equipment codes that do not match Up If the ICD-10 code is not a logical support for the equipment billed, then this is likely to be denied.
• All of the above can be corrected, but only if someone is looking for them before the claim is sent out the door.

What DME Billing Services Actually Do

A dedicated DME billing company does not just clean up denials, they prevent them from occurring altogether, by working on the process to the very end.

Accurate DME Billing and Coding

Specialized billers remain up to date on HCPCS updates, modifier rules and payer specific coding requirements. This alone removes a significant portion of the denials that are caused by these errors in the first place.

Prior Authorization Management

Professional DME Billing Services will monitor the process of prior authorizations with the payers and equipment types so that the approvals are obtained before the same equipment leaves without being identified as a problem when it returns due to a denial.

Clean Claim Submission

The term “clean claim submission DME” is not a marketing term but rather a term that is used to describe claims that are complete, accurately coded and properly documented the first time. The more clean the claim, the quicker it will flow through the payer’s system.

Ongoing Denial Management

But when a denial does occur, a good billing partner doesn’t simply re-submit without any real thought. Denial management involves pinpointing the problem with the coding error, missing documentation, authorization gap, and resolving the problem to prevent the same error in the future on future claims.

How DME Billing Services Speed Up Payments

Fewer Denials Means Faster First-Pass Payment

The quickest route to payment is easy: do it right the first time. Claims that go out clean, payers process and pay claims without a denial and resubmission process.

Dedicated Follow-Up on Outstanding Claims

DME billing companies do not leave unnoticed claims in a queue; they actively monitor them that are pending, flagged and even those that have exceeded the normal turnaround time. This proactive follow-up can greatly reduce payment timeframes.

DME Billing Software and Automation

The contemporary DME software for billing alleviates the coding mistakes, absence of data and authorization issues before the claim is submitted. Together with knowledgeable billing personnel, this identifies issues automatically, not just by manual review.

Medicare-Specific Expertise

Billing teams that specialize in DME are well-versed in the DME Medicare billing guidelines, so they don’t get caught off-guard by Medicare specific denials.

DME Billing Best Practices Worth Knowing

Here are some of the best practices to consistently minimize denials, whether you’re outsourcing billing or processing it in-house:

• Check eligibility and coverage prior to dispensing equipment
• Ensure the prior authorization is complete (not just submitted)
• Always verify the HCPCS codes and modifiers with current guidelines
• Clearly and specifically explain medical necessity
• Pursue claims rather than be denied them.
• Conduct regular audit denial patterns to identify common causes for denial.

Over time, without taking outsourcing costs into account, these practices and suppliers are able to remarkably reduce denials as they incorporate these habits into their operations.

The Case for Outsourcing DME Billing

Why Outsource DME Billing?

Processing claims for durable medical equipment can be handled in-house, but it demands ongoing monitoring of evolving payer regulations, coding updates and compliance regulations. Many suppliers can’t keep up with that in addition to their everyday responsibilities.

Benefits of Working With a DME Billing Company

• Expert coding, which leads to fewer claims being denied.
• Faster reimbursement cycles
• Continuous monitoring for DME-specific regulations
• Greater patient service and operations time liberated due to more internal staff time.
• Use of proven denial management processes, rather than just reactive fixes.

Outsourcing can contribute to the bottom line for growing suppliers, particularly, because the amount of revenue recovered from denials is enough to make outsourcing a worthwhile venture.

How to Reduce Medical Billing Denials Long-Term

Denial reduction is not a “one and done” situation, it’s a continuous process of improving documentation, keeping up on payer policy changes and reviewing denial trends frequently. Suppliers that are doing the best will consider prevention of denial to be a continuous process rather than a problem to be solved when it arises.

Partnering for Faster, Cleaner DME Reimbursement

From the claims payment side, we collaborate with the DME suppliers to minimize claim denials, shorten the time to claims payment, and streamline the time and effort spent by our internal teams on the day-to-day billing process to get the equipment to the patient faster and payment to the supplier faster.

Frequently Asked Questions

What’s the most common reason DME claims are denied?

One of the most common causes is missing prior authorization or outdated and incorrect HCPCS codes.

How long does it typically take to get paid on a clean DME claim?

Clean and accurate claims are typically paid within a few days and are processed much quicker than paid claims that need to be corrected or appealed.

Is outsourcing DME billing worth it for a small supplier?

For most small and mid-sized suppliers, yes the reduction in denials and staff time saved usually outweighs the cost of outsourcing.

Do Medicare and private payers have different DME billing rules?

Yes. In addition to commercial payer documentation and coverage requirements, Medicare will have its own documentation and coverage requirements under Part B.

What’s the difference between denial management and denial prevention?

Denial management deals with claims denied, denial prevention involves catching errors before the claims are submitted, and it is much more effective over the long haul.

Ready to Reduce Denials and Speed Up Payments?

All denied claims are lost revenue, and it can be avoided most of the time. When your DME business is ready to streamline billing accuracy and accelerate cash flow, give QHS Health a call for a complimentary billing assessment and discover just where your process can get better.