Top 5 Flaws and Solutions of DME Prior Authorization

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HME/DME Prior Authorizations are intended to guarantee that patients receive the best possible care at the best possible time and in the most efficient environment possible throughout their treatment.

Advancements in certain aspects like:

  • Medicine
  • Regulations
  • Technology

Mean that payers, providers, and patients alike must traverse increasingly complex medical policy rules and standards. This makes the DME prior authorization process feel arduous for all parties involved.

Streamlining the HME/DME prior authorization process can help relieve that burden. This offers physicians and their patient’s confidence and relief. Primarily because they are receiving the best possible care and their health insurance will not leave them with a bill for non-covered services.

Here are 5 major flaws in the business, as well as ways payers can help enhance the DME prior authorization process’s effectiveness.

DME Prior authorization for non-critical services

Creating work that benefits neither the providers nor the payers’ Authorizations is frequently required by payers for case management rather than a medical review. Consider limiting prior authorizations to services that require medical necessity or policy assessments, such as high-cost oncology care, to overcome this problem.

Consider removing the need for DME prior authorization for preventative checkups, particularly for providers who are performing well under value-based contracts, and utilizing case management systems to handle continuing chronic conditions.

DME Prior authorization is confusing

DME Prior authorization and medical policy requirements can be difficult to grasp without the correct materials, which often confound doctors. To keep track of all the varied rules for different payers and coverage plans, providers and their employees may resort to develop cheat sheets. This implies they might not implement policy changes as quickly as they should, or they might submit authorizations that aren’t required, causing more work for everyone. Consider using electronic tools to explain:

  • When and why a DME prior authorization is required?
  • What information is needed for each type of service?
  • What is and isn’t allowed under treatment guidelines?

This will aid in the simplification of the process for clinicians and their employees by guiding them through the information gathering process and making important medical policy information readily available in the workflow.

Delays DME prior authorization approval

If you want to collect and verify all of the information required to execute a prior authorization request. Numerous phone conversations, emails, and other contacts between both the provider and payer are frequently required.

This suggests that users may have to wait days or even weeks to receive the care they require. Potentially resulting in missed treatments and causing increased stress for patients as well as scheduling issues for doctors.

Whenever feasible, use electronic technologies to streamline the process. It helps to lessening work and enhancing data quality for submissions and status decisions. Look for solutions that allow for online collaboration throughout the process, saving time spent on the phone and exchanging faxes, and that provide a comprehensive audit trail of all interactions.

Lack of accountability in DME pre-authorization

Payers can provide an online status lookup with clear directions when more information is required, minimizing the pressure on payer call centers and streamlining provider operations. Consider providing progress updates and follow-up messages to providers through email throughout the same portal where the authorization was submitted. This aids in keeping them informed quickly and efficiently.

Submission of supporting documents

It is frequently done manually via fax or letter, as it takes time, is difficult for providers to keep track of, and is difficult for providers to match to the relevant permission request. Consider developing a secure online solution that enables providers to deliver information electronically when submitting DME pre authorizations or when further information is sought in the future.

Clear and established criteria specifying the types of documentation required can even enable such systems to automatically collect the appropriate material from a provider’s EMR, saving time and effort for the provider.

Hence to conclude, these are some of the issues that make DME prior authorization one of the most expensive, inconvenient, and complicated payer/provider transactions in today’s healthcare environment. Many of these issues can be alleviated by implementing an electronic HME/DME prior authorization system. This will give clinicians the tools they need to manage their requests and make it much easier for doctors and payers to help patients obtain the needed care quickly.


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