Top Strategies for Resolving DME Prior Authorization Limitations

DME Prior Authorization

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

  • Pharmaceuticals
  • Durable medical equipment (DME)
  • Medical services and insurance authorization services

They are offered to assist with the administrative load involved with the DME Prior authorization procedure. The American Medical Association (AMA) cautions, however, that prior authorization regulations are riddled with issues such as inefficiency and lack of transparency. This jeopardizes patient care and costs physician offices time and money. According to an AMA survey, 69% of physicians waited several days for prior authorizations, and 10% delayed more than a week.

Earlier this year, the Medical Group Management Association (MGMA) announced the findings of a poll that highlighted the expanding scope of the problem. In a mid-May 2017 Stat poll, 86 % said that prior authorization requests and other requests from health insurers for supporting paperwork on patients had increased 4 percent in the preceding year compared with the previous year.

Insurance companies may mandate pre-certification for:

  • Outpatient and inpatient hospital care
  • Observation services
  • Invasive operations
  • Physician-ordered medical tests
  • Clinical procedures
  • Drugs
  • Colonoscopies
  • Medical equipment

They will not pay for the service or drug until the physician submits extensive evidence establishing the medical necessity of the service or drug selection. Furthermore, DME prior authorization policies differ between insurers.

The following are some actions that physicians can take to acquire DME PA and avoid denials:

Understand each payer’s coverage and DME prior authorization policies:

Surgeons must be aware of payer coverage and DME prior authorization guidelines. They must provide the particular diagnosis on their reports. The diagnosis codes reported explaining the payer “why” the treatment must be performed and serve to substantiate the procedure’s medical reason.

Take the following precautions to avoid denials:

Providers must have relevant information about the procedures they usually conduct and use this expertise to enter the contractual process. They should have proof to support the medical necessity of a specific procedure, as well as trustworthy references on coverage for specific diseases. This type of information would also be useful during reimbursement talks.

Even for routine operations, guarantee DME prior authorization:

Imagine procedures such as computerized tomography (CT) scans and magnetic resonance imaging (MRI). As well as brand-name medications, are two of the most prevalent procedures for which insurance needs DME prior authorization.

Check the websites of insurance companies:

Checking insurance websites on a weekly basis will aid in the detection of problems. Patients can be informed about any issue that may affect them so that they can raise it with their insurance company and advocate for themselves and their provider.

Inform the insurer, why the patient is a good candidate for surgery:

To assist patients with their inquiries, the surgeon and/or referring physician can write to the insurance company to justify the patient’s candidacy for surgery. They can use evidence-based literature to back up their claims.

Contracts with insurance companies should be updated:

Insurance companies’ coverage policies may be updated from time to time. To maintain coverage, providers must keep track of these developments and renew their contracts.

Know your diagnosis codes:

This is especially crucial for orthopedic and spine operations, as many of them do not have well-defined codes. The assistance of an experienced medical coding service provider might be vital while negotiating contracts and securing full compensation.

Regular preventative audits

It can discover flaws and assist establish normal denial trends for specific procedures. This will allow providers to address small issues that may be causing a substantial number of denials. The focus of audits should be on diagnosis codes and final payment.

Key takeaways in DME prior Authorization

According to one study, DME prior authorization and medical necessity-related denials account for more than 11% of all denied claims, and this is mainly owing to a failure to get DME prior authorization. Insurance verification specialists at insurance authorization businesses can assist providers in overcoming the hurdles connected with getting DME prior authorization.

They are well-versed in the process and will call insurance companies as well as visit payer websites to seek DME prior authorizations wherever possible. A reputable insurance DME prior authorization provider will have worked with all types of government and commercial insurers.

Collaborating with an expert assists practices in minimizing the time and resources required for obtaining DME prior authorizations, as well as lowering the chance of denials, this benefits both physicians and patients.