How to Prevent DME Prior Authorization Related Claim Denials?


A claim may be denied if DME prior authorization is not obtained before the service is performed. Prior authorization is usually required for high-cost additional services, surgical procedures, or services that are deemed unnecessary in certain situations.

Unfortunately, the requirement for DME prior authorization frequently results in delays in necessary health care. This can have an impact on both patient satisfaction and patient outcomes.

According to an AMA survey, physicians and staff members spend an average of two business days per week dealing with DME prior authorizations. The American Medical Association continues to urge payers to reform their HME/DME prior authorization requirements. It is now critical for your practice to understand how to handle authorizations efficiently for the sake of your patients and practice revenue.

Even if you work hard to deal with DME prior authorizations effectively, claims may still be denied for a variety of reasons. Here’s a closer look at some of the most common reasons for DME prior authorization denials, as well as steps you can take to avoid denials and keep your practice revenue flowing.

Reason 1: Inability to provide the DME Prior Authorization Number

In several cases, claims are processed by an automated system, so if there is no DME prior authorization number on the claim, the system may reject it. If the payer does not perform a manual check, it is possible that they will not realize you received prior authorization.

These denials are usually easily avoided. Simply double-check the claim to make sure that the prior authorization number is clearly visible. It’s a simple fix that can help your practice save time and money.

Reason 2: Unable to Obtain HME/DME Prior Authorization before Treatment

It is sometimes difficult to obtain prior authorization before treating a patient. Especially if the patient is seen on an emergency basis and you do not have time to obtain the DME prior authorization.

If you are dealing with a case of emergencies, you will usually find that payers are willing to be flexible. They do not, however, usually show much flexibility when it comes to non-emergency care.

Reason 3: Payer didn’t process the claim correctly

It’s possible that a claim is denied simply because the payer didn’t process it correctly. If you receive an unexplained denial, it’s critical to have staff who can contact the payer to determine why the claim was denied and whether that reason is justified. When this happens, work through the issue with the payer’s representative over the phone to identify the issue and prevent future errors.

Hence to conclude, even if you take steps to obtain DME prior authorization before performing a service, keep in mind that there’s no guarantee they’ll pay. When submitting the claim, make sure that the service is medically necessary, that the claim is filed according to the payer’s filing requirements, and that the DME prior authorization number is included.

DME Prior authorizations are a common cause of claim denials and can be difficult to navigate for your practice. If a payer denies a claim, don’t be afraid to appeal. While contacting payers to discuss denials is time-consuming, it is very beneficial in changing claim outcomes. A further alternative is to outsource your billing and coding. Professional billing and coding companies specialize in managing claim denials and working to prevent future denials, so that your revenue grows exponentially.