5 effective prior authorization strategies for DME providers.

Prior authorization for Durable Medical Equipment remains a sore point for DME practices and businesses. Frequent authorization denials and subsequent delivery delays result in burnout and frustration. There are limited automation options and for an industry whose success hinges on timely approval of PA requests it is essential to have an effective prior authorization strategy.

1. Standardize the prior authorization request (PAR) process

The prior authorization request must include evidence that the medical item complies with all insurance coverage, coding and reimbursement rules. Relevant supplier provided documentation must be furnished. The request must comply with Local Coverage Determinations (LCD).

2. Ensure that suppliers are conversant with guidelines.

Prior authorization for DMEPOS is a long winded process with multiple stakeholders. It is important that key players in the ecosystem are compliant with prior authorization programs for their particular jurisdiction.

3. Prevent denials. Are you making these common mistakes?

PA denials occur if the patient’s certificate of Medical Necessity (CMN) history indicates that the patient had received a medical equipment that is similar to the DMEPOS item being billed.

4. Pay attention to patient information.

• Patient’s Medicare Beneficiary Identifier (MBI) details.
• The enrollment details of the patient. Check if the patient is enrolled with their employer or a Health Maintenance organization.
• CMN and DIF information.

5. Pay attention to Power Mobility Device codes.

CMS requires mandatory prior authorization for a list of PMD codes. The complete list of medical codes and descriptions can be found here.