What Is Claim Adjudication? Does It Impact My DME Business?

Any experienced DME provider is well aware of the issues that can arise with medical billing. The process often feels like a minefield of denials, rejections, inaccuracies, partial reimbursements, missed deadlines, excluded services, and other obstacles.


These stumbling blocks can be a pain in the neck for clients trying to get reimbursed for treating their pains in the neck. 


By understanding how insurance companies review claims — that is, claim adjudication — DME providers can increase their claim approval rate and save both time and money.


In this blog post, we’ll explore what claim adjudication is, the benefits of preparing claims for adjudication correctly, the challenges associated with it, and how to improve your approval rate for DME claims.

What Is Claim Adjudication?

What is claim adjudication, exactly? It’s the process that insurance companies use to review healthcare claims and make a decision about whether to pay it, reject it, or pay part of it. 


Claim adjudication occurs after DME providers submit claims to health insurance companies. When claims are submitted properly and completely, adjudication will ensure that the information on the claim is accurate and that all necessary documentation has been provided to approve the claim. 


How does understanding claim adjudication help DME providers? Let’s first take a closer look at the benefits of knowing how the process works.

How to Increase Your Number of Approved Claims

The first important step DME providers can take to increase their chances of getting claims approved through the adjudication process is to use tools that automate data collection. The more automations you use, the least likelihood of human error. With the right software in place, DME providers minimize mistakes, verify identities, track and update policy changes, and send the correct information to the right recipients. 


One common problem that occurs in the claim adjudication process is incorrect coding. By auditing your claims for codes on the front end before they are submitted, DME providers can reduce the number of denials, partial payments, or delays. 


Comprehensive data management is absolutely essential for DME providers. Without a central, streamlined system for storing and retrieving your patient and provider data, you might as well be asking for a more challenging time with claim adjudication. It always pays to invest in a robust, secure, and reliable data management system. 


Above all, the best solution for increasing your number of approved claims is to partner with a third-party DME billing service like Medbill. At Medbill, navigating the claim adjudication process is literally what we do every day. Let us do all the hard claims work for you while you focus on running your DME provider business. 

Benefits of Proper Preparation for Claim Adjudication

DME providers can take advantage of a number of tangible time- and cost-saving benefits that come with understanding the ins and outs of claim adjudication. These include:

Reduced Denials

By taking the time to review each claim carefully and ensure that all necessary documentation has been provided, you can significantly reduce denials from insurance companies. This means more of your claims will be approved and paid in a timely manner. For DME providers, this also means saving you time and money — lots of it.

Improved Accuracy

Double check claims for accuracy to ensure claims are clean through the adjudication process. DME providers need to take the time to minimize errors that can lead to delayed payments or denials. As a result, you can expect that more — if not all — of your claims will be paid correctly and quickly.

Increased Reimbursement

When claims are paid correctly, you can maximize your reimbursement levels. This will help to increase your overall revenue and boost your bottom line. 

Challenges of Surviving the Claim Adjudication Process

While there are many benefits associated with proper navigation of claim adjudication, there are some potential challenges, as well. You can expect to need to address the following issues:

Data Accuracy

For claim adjudication to be successful, accurate data must be provided on each claim. If any of the information is incorrect, it could lead to delayed payments or even denials. Overcoming this challenge requires extra attention to detail at every step of the process.

Complex Regulations

The process of claim adjudication is governed by a complex set of government, industry, and manufacturer regulations that must be followed in order for claims to be approved. This can be difficult to keep up with as regulations change over time.

Tracking Changes

As regulations change, it’s important to track these changes in order to keep up with them. This can be time-consuming and requires diligence and attentiveness. 


As with most things that are worth doing, claim preparation can require some extra work as you navigate its challenges. But the benefits you’ll experience will make the extra time and work well worth it.

How to Navigate Claim Adjudication

If you’re interested in improving your ability to navigate claim adjudication for your DME business on your own, there are a few steps you need to take:

Assemble a Team

First and foremost, it’s important to put together a crew of experienced professionals who understand the claim adjudication process and have a proven ability to ensure accuracy on every claim.

Obtain Technology

Preparing each claim accurately requires access to technology that can quickly check for errors and omissions. You’ll need to invest in robust, reliable software programs that can scan your claims for accuracy, track workflow, and streamline the claim adjudication process for you.

Standardize Your Processes

It’s also important to establish processes for reviewing claims and tracking changes in regulations in order to stay compliant with industry standards. When you have a consistent, standardized process for preparing your claims, your team will avoid inconsistencies and be less likely to make mistakes.


Better yet, hire a third-party billing service like Medbill to handle all your claim adjudication for you!

Let Medbill Help You Navigate Claim Adjudication

Managing the claim adjudication process efficiently will lead to reduced denials, improved accuracy, and maximized reimbursements. While it can be a frustrating process to endure, you can reduce your headaches and delays by setting yourself up for success — or hiring a third party to do the hard work for you. 


Medbill can make it easy for you! Let our team of trained and highly experienced medical billing professionals take care of your claim preparation needs. We have streamlined practices in place to ensure that your DME billing is always done accurately, quickly, and efficiently. 


For more information on how to get started with claim preparation for adjudication for your DME business, check out Medbill’s website for resources and further education.


Contact Us