Accurate documentation is key to DME billing compliance. This includes:

Detailed physician orders, also known as a Standard Written Order (SWO) or Detailed Written Order (DWO), which confirm what a physician has prescribed for a patient. These must be signed, dated, and include the exact DME, patient’s diagnosis, patient and physician information, length of need, and any special instructions. For DME drugs under the DME benefit, the order must also specify the drug name, dosage/concentration, duration, quantity, and refills.

The detailed physician order serves as a link between the physician’s prescription and the DME supplier’s billing process, ensuring the correct equipment reaches the right patient and the claim is fully supported for reimbursement.

Streamlining prior authorization (PA) in Durable Medical Equipment (DME) billing involves simplifying the approval process with insurance payers to ensure faster delivery of DME items to patients. 

Challenges include time-consuming procedures, complexity, frequent updates, reliance on manual processes, and high denial rates.

• Around 20-30% of DME claims face initial denials due to errors in documentation and coding, highlighting how common these issues are. An industry report notes that up to 20% of all medical claims are denied on the first submission. Denied claims lead to costly and time-consuming rework, with an average cost of $118 per claim for complex DME cases. Common reasons for these denials include inaccurate coding, missing documentation like patient information or prescriptions, lack of prior authorization, and insurance coverage problems. Additionally, using outdated coding resources and failing to meet specific payer requirements contribute to the issue.