The Medical Director, Director of Nursing, Compliance Officer, and Case Managers make up a typical utilization review committee. Each week they meet to analyze their weekly caseload; deciding what level of care to provide to each patient. This is a cost management measure instituted by medical groups, skilled nursing facilities, home health agencies, and insurance payers alike. Using practice guidelines and clinical pathways they determine what level of care a patient is eligible for and a care plan is produced and implemented. This method of healthcare management was designed to manage patient utilization and control cost by denying unnecessary procedures or prescribing less expensive alternatives. Of course a DME can’t determine what level of care a patient is to have but they can decide whether to accept the patient based on the level and quality of documentation provided by the patients primary care physician or specialist. Doing so can mean the difference between success and failure.
bflow DME Billing Software helps you make decisions like an insurance company.
When you submit claims to Medicare or other insurance payer, your biller is responsible for knowing how to get your claims paid while ensuring you are compliant in each step of your billing process. Your patient’s insurance company, is responsible for paying you for the services you gave to their beneficiary; as long as you’ve met your contractual obligations. For example meeting timely filling limits, billing according to contractual requirements, local coverage determinations or national coverage determinations. So why do you keep getting denied if you’ve met the written requirements? To find a solution, let us explore a few questions:
- Are you required to provide evidence of medical necessity for each claim you submit to your patient’s payer for reimbursement?
- Are you required to provide proof of delivery prior to being reimbursed by your patient’s payer?
- If your claims are audited, are you required to provide evidence of medical necessity to justify the payment you received for those services?
- If your claim is denied for lack of medical necessity will you be required to repay or return money to your payer?
- If you answered yes to any of these questions then you need a process to make predetermination on services prior to delivering equipment to patients.
Otherwise you face becoming identified as a risk for continually submitting claims that will be denied unless you take necessary steps to “Audit-as-you-Go” to ensure your claim meets medical necessity.
With bflow DME billing software you can track the completion of each required step in gathering and collecting medical documentation for each claim. Call us today to see how bflow can help you do more to succeed than the average billing software. Test drive “Audit-as-you-Go” in a live demo today (661) 750 – 8012