In the US healthcare setting, every insurance claim needs to be picture perfect. It is similarly applicable for durable medical equipment (DME) suppliers. They need to ensure that they have delivered the proper medical devices to patients based on their real needs. However, there are fraudulent activities in every industry and DME is not free from that.
DME billing scandals became a nightmare for payers, in fact, some years back. Suppliers often overbill or even double-bill for the equipment they provide. The most concerning issue is, in some cases, suppliers bill for patients who don't even exist. It is sheer healthcare fraud. The DME billing services treated Medicare as a gold mine and extracted significant profit from that. This particular case was referred to as 'Operation Gold Rush.'
Healthcare regulators flagged fraudulent activities to eradicate such practices. This wasn't small change. They initiated this to save thousands of dollars lost in wrong claims. For honest providers, it was a gut punch. If fraud could spiral that far, what did it mean for DME suppliers who were billing for the accurate devices?
Best Practices for Accurate DME Billing Practices
The effect of the fraudulent activities is still affecting the overall DME billing practices. To remain on the safe side, suppliers should maintain optimum billing accuracy. However, here we should know the strategies that will protect suppliers from Operation Gold Rush. Nobody wants such history to repeat itself.
Lesson 1: Good Notes Save You
Documentation is one of the most crucial aspects to justify claims. Insurers thoroughly go through every note and detail. This acts as a testimony to validate the necessity of the device. During Operation Gold Rush, payers cleared many fraudulent claims. It is because charts were vague, incomplete, or entirely fabricated.
After experiencing such incidents, auditors have also become more concerned. They are thoroughly inspecting every detail as providers submit. They ensure the following factors -
This way, DME billing solution providers can thoroughly justify their claims to payers. A clear note will answer all the questions payers may have.
Lesson 2: Oversight Is Here to Stay
The Gold Rush scandal has significantly tightened the claim process. That includes the overall scrutiny by payers and regulators. Medicare has also become more sensitive about fraud claims. They now run sophisticated data checks to justify every DME claim. Commercial payers are also following the same.
Hence, if a DME supplier now orders a large amount of equipment, it will attract payers' attention. They will thoroughly scrutinize the claim. Now, suppliers can send claims for what is prescribed. However, they must ensure to payers that they are not overbilling. These devices are actually recommended by physicians.
Lesson 3: Utilize Technology Wisely
In this digital age, technology or software has no alternative. However, the concern is that technologies are not free from human interventions. Fraudsters has utilized this loophole to gain monetary profits. They notably exploited electronic billing systems to process fake claims quickly.
After seeing such misuse, payers became more concerned. They are now depending on the systems that accurately flag inconsistencies. Hence, we can say that now payers are utilizing software as a safety net. They have developed systems that are able to flag any mismatch between claims and supportive notes.
Moreover, now payers are maintaining compliance dashboards. These updated dashboards efficiently track abnormalities. At the same time, they are also manually scrutinizing the whole claim to ensure no oversight.
Lesson 4: Be Careful Who You Sign With
Another concerning aspect of Operation Gold Rush was that DME suppliers were contacting physicians for signatures. Physician notes help claims to process seamlessly. Suppliers were taking these benefits for a few more dollars. However, these activities make payers more sincere and they consider in detail before claim processing.
Now, payers are thoroughly looking into whether a supplier pushes paperwork across without patient context. It is a sheer problem. Moreover, the insurers are also identifying physicians signing such fraudulent DME bills. They are particularly ensuring that doctors only sign the notes containing the proper and valid DME supplies.
Lesson 5: Update or Get Left Behind
Physicians and DME suppliers know their domains in detail. However, they often lack billing knowledge. Activities that used to get green lights earlier, now may have become frauds. Hence, DME billing staff must know the scenarios in detail.
Moreover, healthcare authorities update regulations from time to time. Hence, billing staff must know the latest rules to stay compliant. Regular updating will save DME billing from denials or noncompliance. Suppliers should know the up-to-date Local Coverage Determinations (LCDs), billing changes, and fraud trends. It will enable them to stay compliant.
Fraudsters may treat Medicare like a gold mine, but for DME suppliers, the real treasure is integrity. They must put in extra effort not only to protect patients but to protect their license.
How an Outsourced DME Billing Company Can Save Your Practice
Outsourced or overseas DME billing services bring optimum expertise. These vendors have qualified billing specialists whose first priority is to protect the practice. Hence, they maintain maximum claim accuracy. Moreover, these third-party billing solutions are significantly cost-effective.
Billing experts like SunKnowledge offer top-notch medical billing and end-to-end RCM services for just $7 hourly. When they take care of the administrative responsibilities, suppliers can save about 80% of office expenses. Moreover, free from operational hassles, suppliers can centralize their focus on enhancing their equipment collections.
