Prior Authorization for DME: As We SEE

A Story by John Carter

Prior authorization for DME involves a lot of complexities and technicalities in its process, which is very aptly handled by professional prior authorization services.

As industry insiders, we know how complicated prior authorization for DME has become nowadays. Medical practices dealing with Durable Medical Equipment (DME) were already in trouble with prior authorizations. The reason behind the existing apprehension is the realization that prior authorization for DME requires a lot of expertise, which in most cases is beyond the scope of the in-house staff due to inadequacy in training and tools. Working in limited scope increases the turnaround time and raises the risk of rejections. On the other hand, regular training increases cost and takes away time from actual operations. An understanding of the process will help realize the possible hiccups involved in the prior authorization for DME process.

Prior authorization for DME: The Process in Place

The prior authorization for DME commences with a request for approval subjected to coverage of the required equipment or device. Next is the submission of the request for review before the claim is submitted for payment. The process involves a lot of conditions related to adherence to applicable coverage, payment, and fulfillment of coding rules for the approval mechanism. It seems in theory but it comes out a lot more difficult process to get rolled out. Delays in getting the approval affect both the patient and physicians and result in uncomfortable situations. This gets worse during the critical cases where treatment should not get hindered. Prior authorization executives ideally should have a thorough knowledge of right coding, proper filling up of forms, etc. to get the job done as desired. However in-house staff stumbles on various steps making the process gets interrupted.

The Final Rule Effects

The CMS-issued mandate - Final Rule has been issued in the recent past, which aims prior authorization for some DMEs, prosthetics, orthotics, and supplies (DMEPOS) to check the rising prices and increase transparency in the process. The Final Rule states that a Master List is being created, which contains 135 DMEPOS items. The validity of those items in the list is for 10 years from the date of addition. Although some amount of clarity has been brought to the process it has also added further complexities with the technicalities increasing.

Profession Help is the Need of the Hour

As the billing executives of the medical and healthcare providers struggle to handle prior authorizations for DME, the owners of the practice have heaved a sigh of relief with the presence of professional prior authorization services. A lot of the medical practices have been able to restore normalcy within their practice by outsourcing their prior auth woes. The reasonable service charges offered by the prior authorization companies, which can be as low as $5-$8 per auth/hour has cleared the smog around outsourcing. With the prior auth service providers providing insurance support for any error from their end, the clients have no qualm in handing over their prior auth process to them.

As observed, the immediate impact on the medical practices after the outsourcing has been the achievement of reducing billing costs by around 80%. With 100% client satisfaction in mind, prior auth service providers are being largely successful in creating a seamless implementation of achieving a successful prior authorization for DME process.