A denied medical claim happens when a payor (usually an insurance company) does not approve payment for a claim your office submits. This can happen for a number of reasons, including but not limited to: 

  • An insurance company deems a procedure or piece of equipment medically unnecessary
  • A patient may have a limited amount of coverage
  • You are not in the patient’s network
  • An error on the claim form itself

With fluctuations in DME billing requirements and varying medical coverage by payors, your practice could see an increase in claim denials. To help collect on as many claims as possible, here are our three top tips for appealing DME claim denials.

1. Don’t Waste Time

Many practices simply resend the same claim with supporting documentation and just wait, hoping for an insurance payor to change their mind. Often, this is just a waste of time.

Instead, send in a formal appeal letter to the payor directly. It may take more time than simply sending in the same or similar documents, but there are many benefits of this extra effort:

  • Insurance payors will feel motivated to research your issue more in-depth and resolve it more quickly than if you simply resubmit a claim.
  • Many insurances allow appeals to be submitted via their web portal electronically. Take advantage of this feature for the most expedited and verified method of submitting appeals. You can also track the progress of your appeal if submitted online.
  • A formal appeal letter shows that you take the claim denial seriously.
  • Taking the time to actually write out the letter will get your practice to more carefully review the information on the claim and the supporting documentation.

Be Timely

It’s important to send in a formal claim appeal letter as soon as possible. The faster your claim gets approved, the faster you can receive a payout for the equipment provided. This will also put your patient’s minds at ease.

Note: Insurance providers often specify a timeframe for appealing the claim denial. There may also be state laws specifying how long you have to submit your appeal. 

2. Carefully Review All Documents

The absolute worst thing you can do when appealing a DME claim denial is to send in documentation with errors in it. It tells an insurance provider that your practice is careless and will only result in another denial.

Both your appeal letter and all of the supporting documentation should be free of any errors. Make sure that:

  • Medical documentation is accurate, appropriate, and relevant
  • Diagnoses (both present and past) are accurate and fully supported by medical documentation
  • Healthcare Common Procedural Coding System (HCPCS) codes are accurate
  • Authorization Approval Number included on claim
  • Any modifiers for special conditions or circumstances are accurate

Note: HCPCS codes are extremely important for DME claims. For example, if you send in a claim for a piece of DME that contains the same or a similar HCPCS code as a claim previously submitted, a payor might deny the claim based on a lack of medical necessity. In other words, an insurance provider may assume that the patient already owns the necessary DME, and it isn’t necessary to provide any more.

If a Patient’s DME is Broken or Lost

To appeal a claim in a circumstance like this, you would need to demonstrate that the DME needs to be replaced. A piece of DME that has been broken or lost will require a replacement modifier code.

3. Take a Proactive Approach

Being proactive when appealing DME claim denials is more than just making sure all the coding is correct and the proper signatures are there, although that is crucial. It’s about being prepared ahead of time for a claim to get denied. 

Get Familiar with Different Claims Processes

Each payor has a different policy regarding their claims appeal process. Carriers may have different claims submission practices, timeframes, and requirements. That’s why you should keep an up-to-date running list of the claims appeal process per payor. Take it a step further and write down specific reasons why a claim was denied to provide more insight for future claims. 

For example, if a certain carrier denied your claim due to “untimely filing”, make a note of that in your DME billing management documentation. Ideally, you would be able to search up the claims process for a provider whenever you need to appeal a claim and all the related information you’ve gathered is in one convenient place.

Open Communication with the Patient

You need to keep an open, transparent conversation with your patients so that they can understand what costs they might incur if their claim is denied, how they may help in the appeals process, and so that your patients can answer any important questions to clarify errors in your documentation.

For example, say a patient’s record does not have enough details about their chief complaints and treatments in the past. During a visit, you may communicate with them about their previous treatments. They could potentially point you in the direction of a provider who may have the details you need to complete your appeal.

Keep Record of Everything

Keeping highly detailed records of both your patients’ appointments and your denied claims is crucial to getting claim denials overturned and avoiding issues in the future.

Streamline Your DME Billing Process

The best way to avoid DME claim denials is simple: implement technology and expertise designed specifically for DME billing.

That’s where SelectOrtho comes in. Our specialized DME software helps you keep all your records in one centralized place and keeps you up-to-date on insurance claim practices by insurance providers. Additionally, our DME billing and compliance experts are highly trained in appealing claim denials.

With SelectOrtho’s DME billing software and management, our partners have increased their DME claim approval rates from 60% to over 95%. We can help you get paid with the first claim you submit and manage claim appeals for those that are not approved.

Consider how much you could be collecting without the back-and-forth of claim submissions and denials.

INCREASE YOUR COLLECTION RATE