Medicare Rules Contributing to a Fraud Free DME Billing!

Information is out of date

Long-standing concerns in DME (Durable Medical Equipment) known for unquestionable billing practices, led the government to take action for tackling fraud in the insurance industry. Medicare, the nation’s largest health insurance program, regulates the billing structure of the maximum number of healthcare providers. Due to its highly fragmented nature, Medicare is prone to widespread fraud thereby rising healthcare costs, taxes, and premiums. DME billing is the process of submitting and receiving payment for a claim from the insurance company.

Medicare pays for services given to the severely sick/disabled at home such as wheelchairs, arthritis kits, etc. But many DME companies supply cheap or bad quality equipment at good quality equipment rates to make profits or sometimes bill Medicare for equipment never provided. To crack down, on this fraud, the Centers for Medicare & Medicaid Services (CMS) issued new rules catering toward reducing needless consumption and aberrant billing amongst DME and supply companies.

According to medpagetoday.com, “Specific durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that are most commonly and unnecessarily overused will be subject to an updated authorization process that will, for some items, require prior approval before Medicare will pay for them. Not involving any new documentation, this prior authorization will oblige companies to validate relevant coverage, coding, and clinical documentation concerns before a beneficiary receive a product and before a Medicare benefit claim is submitted. Modifying the process in this way will prevent beneficiaries from being forced to pay for items that aren’t covered by Medicare.”

CMS also created a master list containing 135 items that are subjected to prior authorization before the equipment is provided to the beneficiary. It should have an average fee of USD 1000 or greater or a rental fee of USD 100 or greater.  Also, CMS highlighted a 3-year prior authorization demonstration project for power mobility devices (PMD – wheelchairs, scooters, etc.) to reduce expenditures.