Since this pandemic, the business cycle of healthcare providers is being impacted by the introduction of new rules and subsequent revisions. Moreover, Today’s DME prior authorization departments are in a precarious position.
- Reduced reimbursements
- Competitive bidding
- High labor costs
Are likely to be felt by those in this industry, even as the demystification of medical knowledge.
It’s also worth noting that technological improvements are having a huge impact on day-to-day operating processes. While practice management engagement in DME Prior Authorization is not a new occurrence, its effective administration appears to be a barrier for the majority of practices.
The Back Story
CMS published a rule requiring prior authorization before Medicare would cover DME that had been proven to be prone to inappropriate and fraudulent payments just as the year was coming to a close. The Office of Inspector General of the Department of Health and Human Services (HHS) and the Government Accountability Office (GAO) made a point of emphasizing financial issues about:
- Wheelchairs
- Prosthetics
- Orthotics
Their fears were justified: the Council for Medicare Integrity had revealed a 53.1 % error rate for DME billing in FY 2014, resulting in $5 billion in erroneous payments, the previous October. The rule was supposed to save Medicare $580 million over ten years, so it’s worth checking in on how things are doing now.
What do they lack?
They often lack the internal competencies needed to tread a fine line between economic security and a client strategy. We’ve seen companies invest a ton of cash to attain streamlined uniformity in their pre-authorization procedure nowadays.
The implementation, on the other hand, falls well short, with a shoddy technique that destroys any chance of adequate democratic accountability in the benefits of the verification process. Prioritizing the DME PA process might be challenging for businesses due to a lack of understanding of the insurer’s claims adjudication procedure. A particular skill set is required for DME Prior Authorization service.
Due to the compelling need to maintain the long-term viability of the entire DME PA process, we now find a slew of third-party suppliers providing services in the authorization sector. Some of the top challenges that might be costly during verification services are as follows:
Correct CPT Code
The accurate CPT code is essential for a successful DME prior authorization. The difficulty is that you must decide the correct procedural code before the service is delivered (and documented), which is a challenging effort in and of itself. Check with the physician to see what he/she plans to do to determine the correct code. Make sure you cover all conceivable eventualities; otherwise, you risk not being reimbursed for a surgery that was performed.
Priorities for claim evaluation
The majority of practices lack a centralized structure that can provide them with automated updates on new changes or a thorough understanding of specific insurer’s policies. Their DME prior authorization does not meet the requirements, and as a result, timely feedback is ignored, resulting in problems throughout the denial management process.
When you don’t have the required DME prior authorization
The patient’s insurance plan is frequently used to determine who is accountable. If the plan benefits specify which services are not covered and the patient wants such services, the patient is responsible for payment. If a physician fails to obtain DME PA for treatment before giving services to a patient and the insurance company denies payment, the provider may be required to absorb the cost of treatment, with no payment due from the patient.
Some payers may hold the patient fully responsible for a procedure that did not have the required DME prior authorization. In this instance, the practitioner must decide whether or not to pursue the patient for payment. Some people are able to bear the loss. Others may mail an unpaid bill to the patient, but this is unethical. Patients are both unaware of the procedure and unable to determine which CPT code should be given to the insurance company.
Key takeaways
As the current scenario is growing more complex and we are moving towards a phase of uncertain times. DME prior authorization is becoming a much more complex procedure than ever before. Therefore, it always suits you better if you take certain outside help to guarantee success in your healthcare firm in the near foreseeable future.
