Durable Medical Equipment billing is a challenging process because it entails understanding how to code claims, requirements to bill and when to submit claims. Off late there have been several instances of wrong billing either due to lack of knowledge or as a fraudulent attempt to make money. DME billing fraud comes in many hues and colors.
One common form of fraud is billing for items not ordered or not received. The discrepancy comes to notice in the Explanation of Benefits (EOB) or Medicare Summary Notice (MSN) paperwork. Sometimes fraud also happen when a patient gets a different type of equipment than one prescribed by the doctor. Other forms of fraud include receiving a phone call for Medicare information from someone not related to the physician’s office. No matter how a fraud is committed, Insurance companies detect fudged billing with great expertise.
Some common DME billing discrepancies identified by insurers include markups above prescribed standards, billing for duplicate orders, higher-than-normal rental charges for equipment or billing for DME component parts in fragments than as a complete unit. Some of these happen as mistakes committed due to oversight. But they get interpreted as frauds and can lead to heavy fines or a ban.
| Common DME frauds: Billing for medical equipment, which is not needed, not provided or not eligible Bribing physicians and patients to submit false claims Bribing for patient referrals Forging medical records Upcoding or billing for more expensive items than that delivered Stealing physician or patient identities to furnish false claims Deliberately supplying defective equipment |
What is DME and What Part of Medicare Covers it?
As per Medicare, Durable Medical Equipment, is a reusable medical equipment, mandated to be used by a patient to handle a medical necessity. It is the doctor who takes a call on what equipment a patient might need as per Medicare guidelines. If a patient meets a coverage requirement, Medicare Part B will provide coverage for the durable equipment. Two things that needs to be borne in mind here is that Medicare pays just for one equipment for a specific ailment at a time and it reimburses for the elementary equipment that has been prescribed.
DME Items Covered by Medicare
The list of durable medical equipment covered by Medicare is huge and cannot be listed in one go. However, a few widely used durable medical equipment items that are usually covered by Medicare Part B include blood sugar monitors, blood sugar test strips, Infusion pumps (some medicines need these), Crutches, CPAP machines, Hospital beds, Nebulizers and associated medications, Oxygen equipment along with accessories and supplies, pressure-reducing beds and mattresses, prosthetics, suction pumps, wheelchairs, walkers, etc.
| How Does Medicare Cover Durable Medical Equipment? Once you have the doctor’s prescription that prescribes a particular equipment, a patient needs to take it to any supplier enrolled with Medicare. Medicare will bear 80 percent of the approved amount (after the patient meets his Part B deductible), and the 20 percent balance is borne by you. |
At times as DME equipment biller, you may be at your wits end trying to figure out if the equipment is covered or not. If you are not sure that an equipment would be covered, get in touch with plan provider. Likewise, you can, talk to the physician or clinic to see if it’s medically mandatory and then contact Medicare. The interesting part is that Medicaid provides coverage for some items while Medicare may not provide the same. So, you need to be extra careful to while cross checking.
While being aware of all the above is important, it is also important to keep in mind that Medicare does also covers certain prescriptions, supplies, and medication that a patient may have to use with their durable medical equipment item.
Criteria for a DME to be Covered by Medicare Part B:
The need for an equipment has to be prescribed by your doctor or health care provider
- It has to be prescribed as a [art of treatment for an illness or injury
- It is necessary to be used at home (though it may also be for out-of-home use)*
- The equipment must last for three or more years
- The equipment has to be provided by certain medical suppliers approved by Medicare
*Note: In case of patients staying in long-term care facility, the facility is considered as home by Medicare. However, this rule doesn’t apply for a skilled nursing facility.
| DME Items that Medicare Does Not Cover Medicare does not cover the following types of DME items and supplies: Items that require home modification such as installing new doors Equipment sought for use outside homes Equipment that are not meant for home uses Equipment for providing comfort (ex. AC)Disposable items which are part of equipment usage (ex. catheters). |
Ways to Streamline DME Billing
Streamlining the DME billing process helps a lot in better reimbursements. This means having the right checks and balances in place. It also means having a consistent prior authorization and a comprehensive accounts receivable process.
Ensure Correct Documentation
Your DME billing can be correct only when the claims submissions are accurate. For instance, when the HCPCS code ends in” 99,” you must furnish required supporting documents to get the claim. Without these, the insurance company will suspend the claim. This can lead to needless delays. Even here it helps to dial up the provider for a confirmation. It helps you to stay update with the latest change in provider requirements and adhere to the same.
Establish Medical Necessity
As per DME coverage guidelines, it is mandatory to show that the need is for a medical necessity. This will help to establish that the equipment is needed to assist in the treatment of their diagnosed medical condition. Local Coverage Determinations are a set of guidelines that help to identify the need for DME items. As a DME biller you need to be fully aware of the specific LCDs for your area to ensure claims reimbursements in first submissions.
Proper Prior-Authorization Process
A comprehensive eligibility verification and authorization process can make DME reimbursements lot easier. And the best way to ensure this is to have a prior-authorization technology in place. What works better is to integrate your electronic prior authorization tool with your EMR. It will upgrade and expedite prior approvals in a proactive manner. This helps in having better control over denial management.
A Robust Accounts Receivable Process
Managing present and aging DME billing accounts require a delicate balance. To acquire this balance, you must equip your team with the most advanced DME billing application. The process must be driven by critical metrics such as accurate and timely filing to the fullest. Likewise, you must train your team to understand payer’s prerequisites. This makes recovering aging accounts very easy.
Streamline Your Billing Services
A robust medical billing system has a direct impact on DME billing process. For instance, it helps you stay updated when there is a change in guideline. This will serve as an alert to check for DME billing updates before submitting claims. Besides it helps in keeping tabs on denials, maintaining an inventor, set targets for denial correction etc. When you have full control of each of these, your DME billing process gets directly benefitted.
| How to stay up-to-date with DME market trends Here are the best ways in which you can stay updated on DME billing updates. Subscribe to online/print trade journals and magazines. Surf the net for any interesting news or articles about the DME industry. Create RSS feeds related to DME; get them mailed to your inbox. Visit the DME Equipment Center on CMS.gov for latest updates or existing policy changes. |
Who We Are and What Makes Us an Expert?
This article is brought to you by Med Billing Experts, a healthcare BPO service provider with wide experience in providing Durable Medical Equipment billing services for a range of US-based healthcare providers. From data entry to filing of claims, from statement for practices to payments and audits, and from DME denial management to customized reporting, we specialize in a gamut of services. Aside from these, we make sure aging reports are followed-up after submission, so that they get reimbursed in the shortest possible time. If you looking to outsource your DME billing services get in touch with us now.
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