There is a distinctive difference between billing for Durable Medical Equipment (DME) services and other clinical procedures – durable medical equipment services are ancillary to the primary clinical purpose, and their admissibility is subject to certain conditions. One of the best ways to overcome the DME billing challenges is outsourcing the DME billing services and RCM system. Physicians since long have found these conditions tricky and challenging to understand, and often either been denied or underpaid for DME services, which may either have been
- Deemed medical unnecessary,
- Uncertified by Medicare/Medicaid/private health insurers,
- Beyond the permissible reimbursement level
- Lack of solid grounding in the Healthcare Common Procedure Coding System (HCPCS), which governs level II codes designated for DME equipment and supplies
While physicians have the right to recommend DMEs as part of clinical treatment, they will have to back their recommendation with sufficient proof of them being medically necessary. Proving medical necessity alone will not suffice; it is equally important to know whether or not a patient’s health insurance coverage supports DME services. With Medicare, Medicaid, and even certain private insurance schemes cautious about supporting exorbitant DMEs, physicians would do well to verify whether or not patients’ health plans support DMEs.
Reimbursements are subject to the condition that physicians or patients source the admissible DMEs from payer-recognized vendors or manufacturers. While this condition may endorse payers’ commitment toward quality DMEs that last long and are competitively priced, physicians will certainly be put through the process of identifying Medicare/Medicaid/private insurer-recognized vendors or manufacturers. What is more interesting is that Medicare has designated certain pharmacies that can only supply admissible DMEs. Therefore, physicians’ task of identifying and sourcing DMEs has certainly become more complex than ever.
DMEs have grown to be clinically superior and functionally perfect these days. While appreciation of quality has facilitated clinical efficiency and patient well-being, the price has been a major issue. Payers have not been all that receptive to the idea of supporting DMEs that are not operationally viable. Medicare/Medicaid too has its reservations against highly-priced DMEs and has put a ceiling on DMEs reimbursements. Physicians, therefore, need to be aware of these restrictions while encountering patients that require DMEs well beyond their insurance eligibility.
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