How DME Prior Authorization Can Be Improved?


DME Prior Authorization (PA) can be a time-consuming and frustrating process. Indeed, According to the American Medical Association (AMA), 86% of physicians rate the administrative burden of prior authorization as high or extremely high.

Prior Authorization caused a treatment delay for 90% of healthcare providers. 60% of those polled said it took at least one business day to receive a response, while 26% said it took three or more business days.

Why is DME Prior Authorization Necessary?

According to the AMA, DME PA is the process by which physicians and other healthcare providers must obtain advance approval from a health insurance plan before delivering a specific:

  • Procedure
  • Service
  • Device
  • Supply
  • Medication

Prior Authorization check whether the patient is eligible for insurance coverage or not.

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DME Prior Authorization plays an extensive role, as it:

  • Helps to control costs and manages the risk of over-prescribing
  • Ascertains that the service or drug requested by the physician is medically necessary
  • Ensures that the service is not duplicated, especially when multiple specialists are involved
  • Determines whether a recurring or ongoing service is beneficial to the patient's care

How Can DME Prior Authorization Be Made Better?

Make the procedure more automated

88% of DME PA is done manually, in part or whole, and is frequently done by phone or fax. Before the request is finally approved or denied, it may take hours, days, or even weeks. DME Prior Authorization can be processed electronically from the provider and payer with the help of automated solutions.

Using Automated DME PAs speeds up the process and reduces PA turnaround times by allowing:

  • Healthcare providers
  • Payers
  • Pharmacies
  • Manufacturers

To all be on the same page, access, and share data instead of each working independently. Moreover, it connects the dots through phone calls, emails, and other means.

Make a list of all the medications and procedures

Make a master list of the medications and procedures that require Prior Authorization, broken down by insurer, to use as a quick reference when checking DME Prior Authorizations requirements.

 You can use your EHR's drug tier database to estimate whether a prescription will need prior approval, or you can request copies of your payers' Prior Authorization guidelines and drug formulas.

Accurate documentation

The key to improving the DME Prior Authorization process is proper documentation. Unusual or poorly documented cases, as well as the use of shortcuts, will almost certainly be rejected. Make sure you send in a complete request with well-documented patient information.

Minimize Services Requiring DME Prior Authorization

Reduce the number of services that require DME PA to lessen the impact on your practice. By proactively implementing the following, you and your team will be able to focus on improving the Prior Authorization process:

  • Before providing services or sending prescriptions to the pharmacy, double-check PA requirements.
  • Establish a protocol for documenting data required for DME Prior Authorization in the medical record in a consistent manner.
  • Submit an organized, concise, and well-articulated appeal with supporting clinical information within 72 hours if a DME PA is wrongfully denied.

Hire Prior Authorization Experts

Time is money for most healthcare providers. Rather than entrusting this critical process to an inexperienced employee, consider outsourcing it to a dedicated team of DME PA experts.

Take advantage of the most up-to-date technology and eliminate the stress of DME Prior Authorization, consider medical billing outsourcing. It frees up your time so you can concentrate on your patients rather than paperwork.

Hence to conclude, finding a high-quality medical billing service that can function as a seamless extension of your current operations will be an excellent value proposition. Receiving DME prior authorizations on time is critical to providing quick and effective patient care.

The medical billing company should provide a comprehensive overview of how they will alleviate your practice management issues and assist you in generating more reimbursements through effective business checks.

While it will allow your in-house resources to devote more time to care management efforts, you will also save money by working with dedicated resources who are experts in dealing with DME PA.