Unique Strategies to Resolve DME Prior Authorization Challenges

DME Prior authorization is usually required by health insurance companies for:

· Durable Medical Equipment (DME)

· Medications

· Medical services

Insurance authorization services are available to help with the process of administrative burden.

DME Prior authorization policies, on the other hand, are fraught with issues such as inefficiency and lack of transparency. According to the American Medical Association (AMA), undermining patient care are costing physician practices time and money. An AMA survey suggests, 69% of doctors said they had to wait several days for prior authorizations, and 10% said they had to wait more than a week.

Insurance companies may require:

· Pre-certification

· Observation services

· Invasive procedures

· Physician-ordered medical tests

· Clinical procedures

· Medications

· Medical devices

They will not pay for the service or drug until the physician provides extensive documentation certifying the medical necessity of the service or drug selection. Furthermore, prior authorization policies vary between insurers.

According to one study, DME prior authorization and medical necessity denials account for more than 11% of all denied claims. The failure to obtain authorization in advance has been the most common cause. Obtaining DME prior authorization from insurers for specific types of services is a regular frustration for family physicians. Physicians can take the following steps to obtain DME prior authorization and avoid denials:

· Being familiar with HME/DME prior authorization policies

Surgeons should be aware of payer coverage and prior authorization guidelines and include the specific diagnosis in their reports. The diagnosis codes report tells the payer "why" the service must be provided and aid in proving the procedure's medical necessity.

· Knowing steps to protect against denials

DME Prior authorizations can be difficult to navigate for your practice, and they are a common cause of claim denials. When a payer denies a claim, never be afraid to file an appeal. While contacting payers to discuss denials takes time, it is very effective in changing the outcomes of your claims.

Another option is to outsource your billing and coding. Expert billing and coding companies specialize in managing claims denials and working to prevent future denials so that your practice's revenue improves.

· Regularly visit the websites of insurance companies

Weekly visits to insurer websites can aid in the detection of problems. Patients can be informed about any issue that affects them so that they can discuss it with their insurance company and advocate for themselves and their provider.

· Explain to the insurer regarding patient’s critical health

To assist patients, the surgeon and/or referring physician can write to the insurance company justifying the patient's eligibility. They can produce an evidence-based documentation to back up their claims.

· Update contracts with insurance companies

Insurance companies may make changes to their coverage policies at any time. To maintain coverage, providers must keep track of these changes and update their contracts.

· Recognize diagnosis codes:

This is especially important in DME prior authorization for orthopedic and spine procedures, where many of the codes aren't well defined. While negotiating contracts and seeking full reimbursement for certain high-volume codes under diagnoses, the assistance of an experienced medical coding service provider can be invaluable.

· Regularly conduct audits:

Conducting regular preventive audits can help identify issues and typical denial trends for specific procedures. This will enable providers to address minor issues that may be the cause of a significant number of denials. Diagnostic codes and final payment should be the focus of audits.

Hence to conclude, a reputable insurance authorization firm will have worked with all types of insurers, both public and private. Partnering with an expert can help practices save time and money when obtaining DME prior authorizations. As well as reduce the risk of denials, which benefits both physicians and patients.