Confirming Patient Eligibility
We start by verifying if the patient is eligible for DME coverage. This involves checking their insurance, ensuring they meet medical necessity criteria, and getting any necessary pre-authorization or referral.
Prescription and Documentation
Once eligibility is confirmed, we collect a valid prescription from a licensed healthcare provider. The prescription should detail the type of equipment needed, quantity, duration of use, and any special instructions. We also gather all relevant patient documentation for billing purposes.
Assigning HCPCS Codes
Each DME item is assigned a specific Healthcare Common Procedure Coding System (HCPCS) code. These codes help identify the equipment and facilitate billing. We choose the appropriate code based on the type of equipment, its features, and any additional accessories.
Billing Submission
After the patient receives the DME, we submit a claim to their insurance company or payer. The claim includes the patient’s information, diagnosis code(s), HCPCS code(s) for the equipment, service dates, and any necessary supporting documents.
Adjudication Process
The insurance company reviews the claim to ensure it meets coverage criteria and calculates the reimbursement amount. This process, known as adjudication, involves checking patient eligibility, coding accuracy, medical necessity, and coverage rules.
Payment and Denials
If the claim is approved, we receive payment for the DME provided. Payment may be made directly to us or the patient if they paid out-of-pocket. If the claim is denied, we receive an explanation detailing the reasons for the denial.
Appeals and Follow-Up
In case of denials or underpayments, we have the option to appeal the decision. This may involve providing additional documentation, correcting coding errors, or justifying the medical necessity of the DME. We follow up diligently to ensure prompt resolution of outstanding claims.
Documentation and Compliance
Throughout the process, we maintain accurate documentation of patient encounters, prescriptions, claims, and communications with payers. Compliance with coding guidelines and regulations is crucial to minimize audit risks and penalties.
By following these steps, we ensure timely and accurate reimbursement for DME services while remaining compliant with regulations.