DME Billing Claims: Essential Insights and Updates for 2024

In 2024, efficient durable medical equipment (DME) billing isn’t just a necessity—it’s a lifeline for patients managing chronic illnesses. Are you up to the challenge?

With the growing prevalence of chronic conditions like COPD, diabetes, and arthritis, more patients need access to DMEs. Unfortunately, some medical devices can be costly, and insurance coverage is critical for making them accessible to patients.

Reliable DME billing solutions ensure patients have consistent access to equipment, crucial for effective disease management. From technological advancements to telehealth integration, we cover all the critical aspects needed to navigate the complexities of DME billing.

DME Billing Claims: In a Nutshell

Durable medical equipment, such as glucose monitors, oxygen concentrators, and mobility aids, provides therapeutic benefits to patients with certain medical conditions. Consider a patient with a history of diabetes and chronic plantar fasciitis.

After consultation, the podiatrist prescribes custom orthotics to provide better arch support and reduce strain on the plantar fascia. The patient returns to the clinic for his orthotic management and training session, which the specialist bills under CPT code 97760.

Generally, billing DME claims involves submitting documents to insurance companies to reimburse medical equipment and training for equipment use provided to patients. This process typically includes:

• Documentation: Gather documentation that supports the medical necessity of the equipment, along with any relevant medical records.

• Coding: Ensure proper coding of the equipment (HCPCS and CPT) and services (typically, training for using the DME) provided.

• Submission: Submit the completed claim to the insurance company or Medicare/Medicaid for reimbursement.

• Adjudication: The patient’s insurance company reviews the claim to ensure it meets its coverage criteria and processes it for reimbursement.

• Payment: For approved claims, the insurance company reimburses the provider for the cost of the DME, often after deductibles or copayments.

• Appeals: Providers may appeal the decision with additional documentation or clarification in case of claim denials.

Outsourcing DME billing could be the game-changer your practice needs—why struggle with inefficiency when experts can ensure success?

Essential DME Billing Insights for 2024

The landscape of DME billing efficiency is being significantly influenced by the dynamic interplay of technological advancements, rising costs, and a shift toward patient-focused care.

Such elements are reshaping DME and patient adherence in the following ways:

Customizable DME

3D printing technology supports the creation of customized DME, such as prosthetics and orthotics, tailored to individual patient needs leading to better fit, comfort, and functionality.

As a newer technology gaining momentum, 3D printing is poised to impact the cost and time required to produce durable medical equipment, making customized DME affordable for patients.

Rising Costs

The American Action Forum (AAF), a non-government organization, has highlighted a potential increase in DME prices if the Centers for Medicare and Medicaid Services (CMS) continue to delay their competitive bidding program for DMEs.

According to reports, the program garnered over $3 billion in savings from vendors competing on DME products. The bidding paused around the COVID-19 pandemic, but CMS has yet to provide a new timeline.  

Despite uncertain policy changes, it’s best to work with a DME billing outsourcing partner who has updated their processes to ensure compliance.

Patient Empowerment

Mobile apps enable patients to manage their DME usage, track their health metrics, and communicate with healthcare providers. These apps promote active involvement in their care and better adherence to treatment plans.

Such apps also streamline the billing process by allowing patients to track their submitted claims and receive notifications about payments and coverage.

Data Analytics in Billing

Some organizations use AI algorithms to analyze patient data and predict the need for specific DME. This feature ensures timely provision and reduces unnecessary equipment distribution.

Also, AI-driven software has become helpful in automating coding and billing processes. Practices appreciate its ability to minimize errors, speed up reimbursement cycles, identify patterns in denied claims, and suggest corrections.

Telehealth Integration

Telehealth platforms now incorporate DME, enabling remote patient monitoring and management. Devices like glucose monitors, blood pressure cuffs, and CPAP machines transmit real-time data to healthcare providers and trigger timely interventions.

Such remote consultations and adjustments to their DME help patients follow correct equipment usage without frequent in-person visits.

DME Billing Update: Prior Authorization

The CMS has introduced a new rule to make the prior authorization process more efficient. The goal is to ensure better continuity of care and reduce patient disruptions. Here’s a breakdown of what this means for you and your patients:

1. Streamlined Prior Authorization

The new rule ensures that prior authorization can only be used to confirm a diagnosis or verify that a service or item is medically necessary. This helps to simplify the approval process.

2. Continuity of Care

Once prior authorization for equipment or services is approved, it cannot be later denied for medical necessity. This guarantees that patients continue to receive the necessary care without interruptions.

3. Transition Period for Enrollees

If a patient switches to a new Medicare Advantage (MA) plan while undergoing treatment, the new plan must provide at least a 90-day transition period during which prior authorization for the ongoing treatment cannot be required. This ensures that the treatment continues smoothly during the transition.

4. Utilization Management Committee

All Medicare Advantage plans now require a Utilization Management Committee. This committee will review prior authorization policies annually to ensure they align with Medicare’s national and local coverage decisions and guidelines.

5. Validity of Prior Authorization

When a prior authorization request is approved, it must remain valid as long as it is medically reasonable and necessary. This avoids disruptions in your patient’s care and ensures continuous treatment based on their medical history and your healthcare provider’s recommendations.

Takeaway

Stay on top of the latest billing insights to effectively anticipate and address DME billing issues. Tracking billing claims, clinics, and billing professionals can ensure smooth patient care, financial stability, and compliance. This proactive approach helps plan effectively with outsourcing partners for seamless billing operations, including prior authorization.

Tap Into Our Expertise

Avoid being hindered by obsolete billing procedures. At 5 Star Billing Services, our billing experts undergo frequent training to stay current on the latest technology, policy revisions, and fluctuations in equipment prices. 

Be assured that our services are tailored to accommodate your requirements for managing DME billing and guarantee the security of your data. Contact us at 480-999-0180 or schedule a consultation to experience top-notch DME billing services.