Understanding The Ins And Outs Of Billing Insurance For Dme

Billing insurance for durable medical equipment (DME) is a complex and ever-changing process. DME is a medically necessary device or tool that helps patients with their illness, injury, or condition. Billing for DME involves understanding the different payor policies, reimbursement regulations, and compliance across various product lines. It is important to stay up-to-date with industry guidelines and have a solid understanding of the billing processes and critical components. DME billing specialists play a crucial role in ensuring accurate claims submission and reducing the number of rejected claims. The billing process includes verifying patient insurance information, gathering claim documents, confirming claim information, and submitting the claim to the correct insurer. DME billing also differs from other medical billing procedures due to its focus on rentals and the use of HCPCS codes.

Understanding DME billing processes

DME, or Durable Medical Equipment, is a medically necessary device or tool that helps patients with their daily lives at home or in a non-hospital setting. DME billing is the process of submitting and receiving payment for a claim from the insurance company. It is quite different from other types of medical billing and coding procedures and requires specialised knowledge of HCPCS Level II codes.

DME Billing Guidelines

DME billing guidelines can change at any time, so it's important to stay up to date with industry changes. Regularly checking the CMS's website is a good way to keep up to date with Medicare and Medicaid DME guidelines.

DME Billing Specialists

DME billing specialists ensure that all submitted claims are accurate and complete, reducing the number of rejected claims. They also ensure compliance with payor guidelines, check and correct HCPCS codes, and submit and follow up on claims. Outsourcing to a DME billing specialist can help ensure timely payments and reduce the number of rejected claims.

DME Billing Process

The DME billing process involves four major steps:

• Verify patient insurance information when placing the order and gather all claim documents, including the Certificate of Medical Necessity, Prior Authorisation from Medicare (if necessary), and Proof of Delivery for the equipment.
• Confirm all claim information is correct, including HCPCS Level II codes and modifiers' descriptions.
• Submit the claim using the appropriate form (currently the CMS 1500 / HCFA 1500) and to the correct insurer.
• Follow up on the claim as needed.

Tips for Successful DME Billing

• Develop and maintain a strict billing procedure that starts at the intake process.
• Employ appropriately trained staff who stay up to date on industry changes.
• Create and maintain a thorough and efficient billing process to help ensure timely payments and maximise reimbursement.
• Stay current on all DME billing guidelines and payor policy changes.
• Consider outsourcing to a DME billing company to stay compliant and reduce the time spent on billing tasks.

How DME billing differs from other medical billing procedures

Durable Medical Equipment (DME) billing is quite different from other types of medical billing and coding procedures. It requires in-depth, specialised knowledge of all HCPCS Level II codes, as all DME is classified under this level. The reimbursement process is also complex, as more expensive equipment may be rented rather than purchased. As such, DME billers and coders must be aware of how to code claims and when to send them to get the right reimbursement amounts. For example, the code should specify whether the equipment was rented or purchased, and if rented, each day of the rental period should be listed separately on the claim.

DME billing also differs from other medical billing procedures in that it allows for rentals, and it requires HCPCS (Healthcare Common Procedure Coding System) codes. HCPCS codes help identify the billed item or service provided. For instance, HCPCS code E0607 represents a home blood glucose monitor.

DME billing is a complex and ever-changing industry with constantly changing payor policies, reimbursement regulations, and compliance. It is subject to audits and regulation changes, and billing guidelines can be adjusted at any point. As such, DME billing specialists are often required to ensure all submitted claims are accurate and contain all the required paperwork to reduce the number of rejected claims.

DME billing businesses also demand that receivers adhere to all usage, operating, and maintenance guidelines. They must seek assistance if they have any operational failures and provide users and attendants with the proper instructions on how to track and report changes in patients’ medical conditions.

Critical components of the industry

Billing for durable medical equipment (DME) is a complex and ever-changing industry that requires constant learning and adaptation to ensure a successful billing process and timely payments. Here are the critical components of the DME billing industry:

Understanding DME and DMEPOS

It is essential to understand the difference between DME and DMEPOS. DME refers to medical equipment that assists individuals in their daily lives at home or in a non-hospital setting. DMEPOS includes the same DME equipment, along with Prosthetics, Orthotics, and Supplies (POS) items. DMEPOS items are designed for repeated use, have a lifespan of three years or more, and serve a specific medical purpose. Examples include CPAP machines, orthotics like neck braces, medical supplies, and wheelchairs.

Billing Process and Guidelines

The DME billing process is distinct from other medical billing procedures. It demands an in-depth understanding of HCPCS Level II codes, as all DME items are classified under this level. Billing specialists must be adept at coding claims accurately, specifying whether equipment was rented or purchased, to ensure correct reimbursement amounts. The billing process should be efficient, from intake to claims submission, to maximize reimbursement and maintain a positive cash flow.

Industry Changes and Compliance

The DME industry is subject to frequent audits and regulation changes. Billing professionals must stay abreast of these changes to ensure compliance with payor policies and guidelines. Regularly checking the CMS's website is an efficient way to stay updated on Medicare and Medicaid DME guidelines. Understanding the nuances of claims audits and their purpose in ensuring accurate and fraud-free submissions is also crucial.

Role of DME Billing Specialists

DME billing specialists play a pivotal role in ensuring the accuracy and completeness of submitted claims, reducing the number of rejected claims. Their responsibilities include checking and correcting HCPCS codes, submitting and following up on claims, ensuring compliance with payor guidelines, and more. Outsourcing to DME billing specialists can provide access to experts who can process claims efficiently, stay current with guidelines, and free up time for other business areas.

Choosing a DME Billing Company

When considering outsourcing, selecting a reputable DME billing company is essential. The chosen company should act as an extension of your billing department, offering personalized support and a range of services, including A/R, audit assistance, and revenue cycle management. It is important to research and evaluate potential companies by asking questions about their processes, support options, and ability to improve the billing process.

Claims audits

Purpose of Claims Audits:

The primary purpose of claims audits is to ensure that all submitted claims are accurate and free from fraud. Claims audits verify that the submitted claims align with the provided services and equipment, helping to prevent errors, fraud, and abuse.

Types of Claims Audits:

There are several types of Medicare DME audits, including:

• Comprehensive Error Rate Testing (CERT) Audit
• Medicare Administrative Contractors (MACs) Audits
• Recovery Audit Contractor (RAC)
• Unified Program Integrity Contractors (UPIC) Audit

In addition, each private insurance payer will have their own auditing entity.

Preparing for Claims Audits:

To ensure your business stays audit-ready, it is essential to prepare for claims audits in advance. This includes developing and maintaining a strict billing procedure, employing appropriately trained staff, and staying current with industry changes and billing guidelines.

Minimizing Claims Errors:

To minimize potential claims errors, consider implementing the following tips:

• Review your current claims process, denial rates, and reasons for denials.
• Conduct internal audits to identify and rectify potential errors.
• Analyze and make necessary changes to improve the claims process.
• Stay up to date with Medicare and Medicaid DME guidelines by regularly checking the CMS website.

Working with a DME Billing Company:

Outsourcing DME billing to a specialized company can provide valuable support in navigating the complex world of DME billing and claims audits. A reputable DME billing company can offer expertise, help reduce rejected claims, and increase timely paid claims.

Remember, understanding claims audits and maintaining compliance are essential for the success of your DME business. By staying informed, proactive, and adaptable, you can ensure accurate billing and reimbursement for the equipment and services provided to your patients.

DME billing guidelines

Durable Medical Equipment (DME) billing is a complex and ever-changing process that requires constant learning and adaptation to ensure a successful billing process and timely claim payments. Here are some guidelines to help you navigate the world of DME billing:

Understanding DME and DME Billing:

DME refers to medical equipment that assists individuals in their daily lives at home or in a non-hospital setting. It includes items such as wheelchairs, oxygen tanks, blood sugar monitors, and orthotics. DME billing is the process of submitting and receiving payment for a claim from an insurance company. It is important to understand that DME billing differs from other medical billing procedures due to its focus on rentals and the use of HCPCS (Healthcare Common Procedure Coding System) codes.

Stay Up to Date:

Verify Patient Information and Documentation:

Before submitting a claim, verify the patient's insurance information and gather all the necessary documents. This may include a Certificate of Medical Necessity signed by a medical professional and the DME provider, Prior Authorization from Medicare (if applicable), and proof of delivery for the equipment. Ensure that all claim information is accurate, including the corresponding HCPCS Level II codes and modifier descriptions for each piece of equipment.

Choose the Right DME Supplier:

It is important to select an approved DME supplier that is in-network with your insurance company. Your insurance provider's website usually has a searchable database or list of approved suppliers. In-network DME suppliers may be priced differently and may have specific brand preferences, so it is essential to check with your insurer.

Submit the Claim:

Submit the claim using the appropriate form to the correct insurer. The current form, as of the date of publication, is the CMS 1500 / HCFA 1500. However, a private contracted payer may request additional information. Ensure that you have included all the necessary authorization paperwork to increase the likelihood of the insurance company paying the claim.

Consider Outsourcing:

DME billing is a complex and time-consuming process. Outsourcing to a reputable DME billing company can help you stay current on policy changes and reduce the burden of medical billing tasks. A trusted DME billing service can increase timely paid claims and decrease the number of rejected claims.

Frequently asked questions