How to Tackle Improper Payment Rates?

According to CERT (Comprehensive Error Rate Testing) data, the DME billing landscape witnesses an inadequate payment rate of approximately 39.9% that drains out USD 3.2 Billion from the Medicare Fund every year. This error rate is three times higher than the overall National Medicare improper rate, which is currently pegged at 12.1%

The above statistics assert that it has become critical to figure out the principal reasons behind this improper payment rate, and accordingly layout effective measures to reduce this figure. But first, let’s highlight the reasons for this anomaly:-

1. Incomplete Documentation

One of the biggest reasons behind medical billing errors is inadequate documentation. In fact, this accounts for USD 2.6 Billion of the annual USD 3.2 Billion loss borne by the Medicare Trust Fund. Some of the common incidents of these prevalent errors are:-

  • Services being billed to more units than those allowed within a particular time period.
  • Each date of service not being billed separately.
  • The documents submitted don’t have the necessary forms to complete the process.
  • The documents lack physician signatures.
  • The documentation fails to prove that the billed services were actually provided.

2. Medical Necessity Denials

This error occurs when the treatment of a patient does not appear to match the medical necessity criteria as covered by Medicare and other payment policies.

3. Inappropriate Usage of Modifier

Using invalid modifier combination is one of the reasons behind DME denial. Along with accurate coding of treatment, it is important to bill the medical claims with right usage of modifier combinations.

4. Coding Errors

Some of the most common DME coding errors comprise of:-

  • The patient was discharged at a place other than mentioned on the claim.
  • Billed service was unbundled.
  • The code indicates that the service was provided by someone other than the billing provider.
  • Medical documentation carries a different code than the one billed.

 

How to Overcome These Challenges?

  • Prompt and Accurate Insurance Verification

Your insurance verification team needs to carry out an extensive verification process to determine whether the patient is insured and covered for DME services. Moreover, if the patient is covered, the team must further ensure the kind of DME services that the patient is eligible for.

  • Document With Care

Here are some accurate ways to document your DME:-

  • Accurate comprehension of the proof of delivery rules that you should be adhering to.
  • Using the right modifiers to confirm proper documentation required for reimbursement.
  • Obtaining thorough knowledge about the latest policy changes for major insurance carriers with regards to pre-authorization requirements.
  • Avoid Insufficient Documentation

Even the smallest mistake of missing out one signature can deposit your claim in the “insufficient documentation error” category. This can prolong the entire process and also act as a primary reason for denial. Here’s how you can mitigate insufficient documentation errors:-

  • As a payment condition, ensure that your in-house staff, accurately records and documents a face-to-face encounter examination with the patient six months prior to raising an order for a specific DME equipment.
  • Ensure that the physician or supplier who is ordering the DME equipment is actively enrolled with Medicare to receive the reimbursement.
  • Ensure that NPI (National Provider Identifier) of the ordering physician is on the detailed written order.
  • Thoroughly analyze to determine which HCPCS (Healthcare Common Procedure Coding System) codes associated with DME require a detailed written order. 
  • Confirm Medical Necessity

To ascertain medical necessity, you to need to submit precise documents that support the requirement of the DME. Some of the important documents required in this case are:-

  • Provider’s prescription
  • Clinical documentation
  • Patient’s medical record
  • Healthcare center’s clinical and functional status to determine the medical necessity
  • Anticipated benefit and outcome from using the DME equipment
  • Licensed provider’s plan of treatment

Address and Amend

Taking the above mentioned necessary steps can streamline your DME billing process and further amplify your collections and revenues. However, just curating an effective plan is not enough; you also need a proficient team who can put that plan into action. Additionally, it is also important to continuously review the progress in order to determine what’s working and what’s not in order to garner maximum reimbursements from your claims.

By |2019-01-07T06:31:54+00:00November 16th, 2018|Our Blogs|0 Comments

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