Hello, this is Nick Hopper, Director of Commercial Operations for Novus Healthcare Solutions. Today, we're going to discuss denial management within your DME program, areas where a payer has determined that that device or DME product has not met medical necessity in order to be covered, and hence a denial has occurred. Today's learning objectives for DME denial management includes discussing common causes of denials for your DME program, whether it's based off the product, HCPCS code, payer, or even possibly the extremity. Learn strategies to minimize denials upon dispensing of the item and submission of the claim to billing and the payer, as well as examine the appeals processes and tips for success in managing denials that are presented to your DME program. From an overview of denials perspective for your DME program, it is very helpful to understand what a denial medical claim actually is, and that is when a payer does not approve payment for a claim your office submits. Whether it's due to medical criteria not being met, maybe in relation to the HCPCS billing code or the diagnosis criteria being met, times, maybe it's due to timely filing, as well as other varied reasons as we listed here. Now, with the reasons for denials, number one, the insurance company deems a piece of medical equipment medically unnecessary. Depending on the insurance, most notably Medicare, there's a lot of policies that are out there, such as from a Medicare perspective, there's the knee orthosis policy, spinal orthosis policy, ankle foot orthosis policy, et cetera, along with a lot of private payers have their criteria as well. Now, this can be based off of diagnosis criteria, maybe medical necessities that substantiates the prescription of the brace, and at times, more medical information will need to be submitted to that payer to appeal the denial, which we reviewed during today's presentation. A second reason is a patient may have a limited amount of coverage. Depending on the insurance plan, their employer's plan, there may be a limit on DME benefits or maybe even DME benefits aren't a part of their insurance package as well. Third one, at times, this will be determined before the patient is actually seen in conjunction with the other services that they're receiving at your practice, but possibly the patient is on a network and there's no out-of-network benefits. That's also very helpful from a pre-denial screening standpoint of determining that before the patient is seen, so that in the event that they are prescribed a DME device, possibly you're offering a self-pay option or getting a possible referral to an in-network DME provider from your practice as well. Fourth and probably the most common one that we do see nationally is an error on the claim itself. We left a few examples here. There's a lot of different modifiers. The most basic one is right-left RTLT for an extremity-specific brace. A lot of other payer-specific modifiers that are out there, such as the KX modifier showing medical necessities on file for a brace or the GA modifier if you have an ABN on file from a Medicare perspective. A very important area, another area to keep in mind for the billing staff to stay educated on as modifier criteria do change per HCPCS codes as well. Date of service. Maybe there's discrepancy there. Maybe the date of service is too close to a surgery date or there's no substantiating medical criteria showing on that date of service that the brace was needed. Last, a HCPCS code error. There's been a lot of HCPCS codes updates over the past couple of years, splitting the codes from off-the-shelf versus custom, as well as some codes that have been taken away. A good area to always review your fee schedule, ensure your HCPCS codes are up-to-date and can be another factor to avoid these denials. Now keep in mind, DME billing is ever-changing and medical coverage by payers changes and being in the know on the databases with payers as well as with your DME partner is very important, but it does result in an increase in denials as we have seen as well. From a DME denial management perspective, there's some important areas that can be reviewed, whether it's by the billing staff or you as a DME professional, bills your own claims as well. One, verify patient information. Confirm that the patient demographics, insurance eligibility, and active insurance is correct. At times you see discrepancies there, which results in a denial, possibly billing the wrong information to the insurance company where they can't reconcile to their database, or at times even billing the wrong payer. And then when you do bill the correct payer, you have a timely filing issue as well. So basic, but something that at times is seen as well. Prior authorization, a key component, depending on the payers, as well as at times the bill charge or allowable of the brace, the prior authorization threshold or criteria may vary. It's very good to have an understanding when prior authorization is needed by payer. Ensure that does occur at your practice, whether it's a workflow within your EMR or PM system, or even if you are doing the authorizations yourself, how are you notified that you will need to complete this process? Documentation requirements, probably the top one that we see to avoid any type of denials for your DME program. Ensure all documentation is complete and comply it with insurance company and healthcare regulations as well. At times, we often suggest, you know, this comes along with provider education. When they are prescribing devices, ensure in the plan, as well as the evaluation of the patient, that the criteria for that payer is met, showing the need for the brace. And that goes along with those documentations and often really will help not alone with denials, but possible audits from that payer. Fourth one, ensure that you're coding properly. Ensure that your DME items are up to date. You know, you're adjusting your bill charges as the fee schedules change and adjusting for any type of off-the-shelf or custom fit, a split coding as well, and you're meeting the criteria depending on which code you are billing in that fashion. Process processes. Ensure there's no workflow, internal processes, any type of delays with that. Can go along with the four top areas for denial management, but a good area to review as well to ensure there's nothing that is an outlier, possibly increasing your denials. Outsource. Consider outsources and then revenue cycle management processes. So you need another resource to review your billing perspectives on DME. As well as I also encourage, whether it's a vendor or a DME partner or even different LISP serves that your practice or you may be a part of to get recommendations, advice, as well as stay in the know with DME item updates as well. Lastly, utilize technology. Sometimes it's related to your EMR or PM system or maybe other systems you have within your practice. But anytime you can, you know, integrate technology, streamline process, review pain points. Maybe it's a DME software that you've utilized to manage your DME program as a whole, such as early warnings that are in the system or notifications to the individual if criteria is not being met or prior authorization is needed. Anytime we can incorporate technology is the best fashion. AI or artificial intelligence is starting to be a hot topic for programs all across the nation, of course. And possibly an area that can help with the denial and ensuring when you are having a brace dispensed that these pieces are being covered from a criteria standpoint as well, utilizing that technology aspect of things. Now denials will occur within your DME program. The goal is to reduce the number of them, but at times they will occur. So if you get that denial, whether it's in paper or electronic format, now what? Send in a formal claim appeal letter as soon as possible, and timing is really the key with this. At times the payer will present a timeline when that denial will need to be appealed, whether it's within 30 days or maybe some other set timeframe that goes along with that. Typically they will define that, but I would say being as prudent from a timing standpoint and getting these addressed as soon as possible is a key to possibly appealing the denial and being successful with that. Now when you do appeal that denial, ensure you have accurate medical documentation, whether it's from the medical notes, any type of amendments that may have occurred, or if you are billing a custom fit brace that need criteria, how that brace is bent, molded, fitted, adjusted, any type of documentation that goes along with that would need to be submitted as well. Ensure your diagnoses are correct and up-to-date, and do you meet the criteria for that brace per the payer. Ensure your HCPCS codes are corrected as well. At times maybe there was an update that has occurred and possibly an update needed to occur with the most up-to-date HCPCS code. If there was an authorization, include you have that approval number documented, as well as submit that with the appeal if that product did need an authorization, and most notably something we see often is maybe a missing modifier or a modifier needed to be updated from your billing staff. Ensure those are up-to-date and submitted with that appeal. Three, file the carrier's claim submission practices, timeframes, and requirements. Keep in mind these can change as well. Typically from a billing perspective, they will follow other services that your practice is providing, whether it's the clinic office visit, PT, or any other type of ancillary, but make sure you're staying up-to-date. Four, keep your patient up-to-date. If there's a demographic insurance update, keep that up-to-date and submitted with your appeal, and do keep a record of everything, meaning the date that I did submit the appeal to the denial, any further communication or documentation, just to have a paper trail to make sure you're exhausting everything that can be completed in order to appeal this denial. There are three tips to refine your DME denials, one in preventing them, two in managing them, and then three in appealing them as well, and falls a little bit along the billing on the back end, as well as on the clinical aspect of things on the front end to possibly avoid these before they do hit the billing perspective of things. From a billing component, do verify the patient information again and again we state. There's just so many times you see denials because there's a demographic issue or maybe an insurance update or the primary policyholder has changed or submission completion, those different areas. Do double-check documentation requirements, make sure you have those on file, maybe per the payer, the actual documentation has to be submitted with the claims, ensure you have that criteria met and on the back end with that, including any type of amendments that may have occurred by the provider. File claims daily, don't wait on them, mass claim submission, I would review your DME claims, whether it's in a bucket within your DME program, any type of manual process to submit claims or any type of automated components that are utilizing technology that automatically drop claims that is occurring on a regular and daily basis. Constantly review and update workflow processes, where you may be seeing denials that are occurring and something can be updated, whether from a billing workflow perspective or more so on the front end with your providers and clinical staff. Continue an ongoing education process as you do see these denials. Lastly, just evaluate your current platforms, do you have enough technology in order to avoid these denials? We talked about AI, other type of technology components within your EMR or PM system, are those being optimized or do we need to pull in different resources as well? From a clinical perspective, evaluate the provider education on medical criteria coverage and I would say this is ongoing education for your providers that do prescribe braces within your DME program. Should occur regularly and especially when criteria does change and should your providers know what the medical criteria is for a brace, it is dictated and noted in the patient's chart of prescription of the brace. Make sure there's a proof of delivery with each DME dispense, the patient or a patient guardian or representative should be signing for each brace and showing that it was delivery, taking responsibility for the brace and agree to your practice's terms with the billing of the brace as well. Ensure your forms are electronic and stored, even if you do manual paper form, maybe with dispensement or any other type of waivers or compliant documents with your DME dispension, make sure those are turned into electronic format, are on record and available upon denial or appeals. ABN, the Advanced Beneficiary Notice for Medicare or maybe any other type of payer-specific document as well, ensure that is on file and available in the event of a denial and what Most notably and most important, stay up to date with payer requirements, they do change, there's a lot of different listservs that are out there, your DME partner can assist with that as well, as well as, you know, there are a lot of different conferences and different components that can help assist you with staying up to date as the ever-changing world of DME updated per payer. Why is DME denial management so important for your practice? One, revenue savings, you know, every type of denial that does occur results in a loss of revenue from your practice. One, from the billings that you could be receiving, two, the cost of the product as well. So, revenue is a key component which helps drive your collections rate, your overall net revenue, decreasing your denials, those different areas really helps with your revenue metrics. Maintains your revenue cycle management or RCM process, keeps everything flowing very cleanly. Avoids any type of overhead that occurs with denial management and the cost associated with that. Does improve the claim submission process, you know, there is a component where you can evaluate your first pass yield where the success of a claim being covered upon the first submission of that claim and that can be evaluated and where you do manage your DME denials, that first pass yield percentage can increase quite a bit. Lastly, it's very important for your overall business operations. Listed this before, but increases your collections rate, can decrease bad debt, increase that first pass yield as we just discussed. And once again, as we kind of started off with this slide, revenue is the key component. Helping establish that where your DME program is an integral business unit of your practice. Manage these denials can ensure that there is a healthy revenue cycle coming in for your program as well. In summary, DME denial is a key component of your DME program. Prepare, there are many causes of denial. So appeals processes should be a part of your DME program. Whether it's due to an update to the modifiers, the HCPCS code, the diagnosis code, or any other result amendments that may help with medical criteria, ensure that you're exhausting all the options to appeal the denial and show that medical criteria has been met. Personnel, who will appeal denials? Whether it's a combination or separate from a billing or clinical perspective, who will own this process, who works as well as who reviews the success of any type of appeals for denials as well. Most important to avoid as well as a manager of denials, stay current on coverage criteria. Where are there different areas? Where are there different areas where there's updates, whether it's modifier, diagnosis criteria, medical documentation that needs to be on file, any type of HCPCS updates, deletions, additions, ensuring you're staying up to date with your DME partners, the different listservs that are out there. Once again, a key component for your DME program and denial.

denial management

DME programs

HCPCS codes

prior authorizations

appeals process

revenue cycle management