Unpacking the Mysteries of DME Claims Data

A Durable Medical Equipment (DME) claim is a request for financial reimbursement of equipment your business has provided to a patient for use in their home. The Centers for Medicare and Medicaid Services (CMS) sets the rules for what type of equipment is considered DME, how it should be billed, and how much can be reimbursed. 


When the success of your business depends on knowing the finer points of DME claims, the team at Medbill is here to help. This post will unpack some of the most critical issues surrounding these types of claims and hopefully add some benefits to your DME billing procedures at the same time.


What Items Can be Included in a DME Claim?

DME includes items such as oxygen tanks, wheelchairs, and hospital beds. To receive reimbursement for the durable medical equipment your business provides to patients, your business’s billing procedures must be effective. 


One way to make sure your billing practices are on point is to take the time to understand your DME claims data. This data can help you identify any problem areas in your procedures to make needed adjustments.


Know the Rules for DME Claims

CMS sets the rules for what types of equipment are considered DME, how they should be billed, and how much can be reimbursed. This is essential information for any provider who bills Medicare for DME. 


This is important because if a provider does not understand these rules, they could end up billing Medicare incorrectly and, at best, not getting fully reimbursed. At worst, incorrect billing could result in audits or fraud charges against your company. 


Another point to remember is that some private insurance companies also use CMS guidelines when determining reimbursement rates for DME claims. Long story short: get familiar with your DME claims data.


The Key Components Needed for Billing a DME Claim

Not all medical billing requirements are the same. DME claims should include the following essential information (in addition to other possible details):


  • The patient’s name, address, and contact information
  • The type of DME 
  • The date the equipment was delivered
  • Rental or purchase information for the equipment


If you understand these pieces of data and how they fit into a claim, you will be able to submit them for reimbursement more effectively.


Claims Must Be for Necessary DME

One crucial point is that DME must be medically necessary to be covered by insurance. This requirement exists to keep patients safe and ensure that they only receive the treatment or treatments they need. 


If you’re uncertain whether or not a piece of equipment is medically necessary, checking insurance policy guidelines gives the picture of whether something is medically necessary.


Doctor’s Orders: Have a Prescription for DME Claims

A prescription from the treating physician must be on file before any durable medical equipment (DME) can be billed to Medicare. However, there are often discrepancies between what the treating physician prescribes and what gets billed. 


One of the biggest challenges in billing for DME is obtaining a complete and accurate prescription from the treating physician. Incomplete or inaccurate prescriptions are one of the leading causes of claim denials by Medicare. Denied claims equal lost revenue, which is certainly not a good “prescription” for your business.


For DME Claims Billing, No Means No

One final point to note is, according to the Centers for Medicare & Medicaid Services (CMS), durable medical equipment (DME) claims must meet specific requirements for reimbursement to be approved. One of these requirements is that Medicare must not have previously denied the item for reimbursement. This may seem like a no-brainer, but CMS denies millions of dollars in DME claims each year because they don’t meet this requirement. Don’t be the next business to make this costly error.


We understand that learning the intricacies of filing accurate DME claims can require more time, effort, and attention than your business may be able or willing to expend. However, that doesn’t mean you need to accept the consequences of inaccurate or ineligible claims. 


At Medbill, we have the experience, knowledge, and expertise to help streamline how you file DME claims. Contact us for more information about DME claims management or to request a quote for your business.