Durable medical equipment (DME) billing is a complex and lengthy process. Especially when it involves billing the Centers for Medicare and Medicaid Services (CMS) and third-party insurances, it’s not a task that an unqualified individual should do. Instead, there are DME billing specialists who complete special training and education that can perform the job.
If you’re looking for a better grasp of what’s necessary during the billing process, you’re in the right place. This article can act as a durable medical equipment billing guide for anyone wanting to have a basic understanding of DME billing.
What You Can Expect Billing DME
Audits and regulation changes are common within the DME industry. In order to maintain a healthy cash flow, business owners need to develop and maintain a strict billing procedure that starts at the intake process. Then owners should employ appropriately trained staff that stays current on industry changes.
This article will introduce a beginners guide on:
- Billing DME claims
- Staying current on DME billing guidelines
- Learning about claims audits
A Beginners Guide for Durable Medical Equipment Billing
When you submit a claim for payment to an insurance company, it’ll either be accepted or rejected by the insurance company. Claim acceptance from a payer means the insurance is considering that claim in payable status.
Claim rejection means the insurance won’t pay for the claim. Usually, you can resubmit a claim rejection to receive payment. Still, it takes additional time to complete and delays the payment.
If claims are submitted using a clearinghouse, there is an extra level of claims processing that can take place before arriving at the payer for processing. An acceptance or rejection from your clearinghouse normally means that a key piece of information is missing from the claim and is not able to be forwarded to the payer.
So, let’s take a deeper look into the specifics involved with billing claims.
An Overview of How to Bill a DME Claim
Step 1: Verify patient insurance information when placing the order.
Step 2: Gather all claim documents; this can include:
- Order prescriptions
- Certificate of Medical Necessity signed by the medical professional and DME provider
- Prior Authorization from Medicare (if necessary)
- Proof of delivery for the equipment
Step 3: Confirm all claim information is correct.
- Check that the HCPCS Level II codes correspond with the correct DME item
- The modifier’s description matches each piece of equipment
Step 4: Submit the claim using the appropriate form and to the correct insurer.
- As of the date of publication, the current form is the CMS 1500 / HCFA 1500
- The private contracted payer may request additional information
Staying Current on Billing Guidelines
It’s common for the industry to adjust the billing guidelines at any point. Knowing trustworthy resources you can refer to when learning about those changes is important. Here are several reliable resources to refer to during those times.
What To Expect from a DME Claim Audit
Each type of audit has its own purpose, but they aim to ensure all submitted claims are accurate and void of fraud. Some audits you might see are:
- Also, each private insurance payor has their own auditing entities
Preparing for an audit before one occurs is the best way to ensure that your business stays audit ready. Many resources are available to educate you on preparing for one.
More DME Billing Resources
While this article was only a beginner’s guide to billing DME, we have additional resources. Also, feel free to review the news section on our website to see all the information we share.
- Laying the Foundation for a Successful DME Business Model
- Popular Questions About Billing for DME Supplies
- What Do You Need for a DME Audit?
- An Introductory Review of CMS’s DME Billing Guidelines
Contact Medbill to Learn How We Can Be a Trusted Resource
Medbill is a DME billing company with a team of DME billing experts. Contact us to learn how our team can help uncover the areas of your greatest billing needs and provide you with the potential ROI for our services.