With the inception of Medicare in 1965, durable medical equipment (DME) providers have always been the middle people between the doctor and the referral source. Initially, this meant that a prescription was required to prove medical need. While that hasn’t changed, the rules and requirements look nothing like they did in the past. Using documentation rules from long ago may cause denials today.
Then & Now
From the simpler days of traditional Medicare, when the Part B deductible was $75 and nebulizers were rented ad infinitum, the changes in Medicare requirements have been drastic. To eradicate unscrupulous suppliers and mitigate damages to the Medicare program, the home medical equipment (HME) industry has gone through what seems like countless changes just in the types and names of Medicare-necessitated documentation alone. The standard written order (SWO) is the name du jour for what used to be called the detailed written order, prescription or certificate of medical need (CMN).
While Medicare’s CMNs are now a thing of the past, the requirements are more stringent because the SWO is merely one document that proves the item was ordered by an approved treating practitioner. The most critical proof of medical need is found in the medical record or chart/progress notes and they must corroborate what is written in the SWO and other medical necessity documentation. Not always easy to obtain, the treating practitioner’s medical record must stipulate Medicare’s requirements are met for the item or it will be denied in an audit. One specific Medicare guideline to remember is that a single medical necessity document will not suffice in the event of an audit. For example, lab results (e.g. pulse oximetry or blood gas study report) and chart notes should accompany an SWO for oxygen.
Other Third-Party Payers
Although Medicare continues to set precedent over rules and requirements for medical necessity, with more and more Medicare Advantage (MA) plans in action, HME providers have to also stay current on all payers’ guidelines. Staff must remember to not only check eligibility for the patient, but also to wed each payer’s guidelines with the documents rendered by the referral source or treating practitioner. If there is a contract in place, a close examination of the contract before taking orders is essential. For example, does Cigna require prior authorization to dispense a product, and is that prior authorization required for all DME, or is it only for items over a certain dollar amount or certain HME category? To stay on top of contracts and their guidelines, designate an employee(s) to review each contract periodically. If possible, your billing software should keep track of all requirements and alert users when they are about to make a medical necessity error. If the system knows up front that a payer requires a recertification within a three months, it should not allow the reorder to be placed without a recert on file.
The key is deciphering differences between Medicare Advantage rules and traditional Medicare rules. CMS recently issued a final rule affording the HME industry a few reprieves; one such measure of relief is in MA’s rules, which are no longer permitted to be more stringent than traditional Medicare rules. MA plans must ensure that clinical guidelines provide access to the same medically necessary care that someone would receive under traditional Medicare. This means that they must adhere to CMS’s national coverage determinations (NCDs), the local coverage determinations (LCDs) and general coverage and benefit conditions included in traditional Medicare regulations. The best way to notify CMS of nonadherence is to work with your state association and/or AAHomecare. If a Medicare Advantage plan does not allow continued rental payments after the first three months of a CPAP rental even if the patient uses the device as required in the Medicare guidelines, show the payer the recently changed requirement and if they don’t acquiesce, contact your state and/or national association.
Another recently released requirement was the 72-hour rule for authorizations. Beginning primarily in 2026, payers will be required to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for regular requests. This should help the HME provider, because some payers are taking much longer than 72 hours and seven days to respond to an authorization request. There are other rules centered around authorizations but this rule requires a specific denial reason by the payer explaining why the request was denied.
Operational Impact
As I work with HME providers around the country, I can see that documentation is a bottleneck in claim submission holds. For companies that automate and require documentation before dispensing product, their claim hold status is minimized.
One order intake issue is having an errant payer selected by the intake/eligibility team. Imagine how challenging it must be for employees to store all of the payer information in their heads as they check to see if the patient is eligible today. For example, is the payer contracted with your company, are they primary or secondary, are you contracted for Medicare members or just commercial members? All of these questions and so many more must be answered before determining the viability of the order.
Some companies check eligibility multiple times because of the lack of consistent knowledge in securing this information. This causes multiple unnecessary touches to each order. It’s better build an automated list of payers you can accept so intake doesn’t have to delve so deeply. The best case scenario is for your billing software to maintain this information and alert the intake team during the eligibility check. If this is not possible, at least develop a shared, accessible payer grid that includes payer eligibility by plan, medical group, etc. Continue to track and trend denials for wrong payers and ineligible patients. Retrain employees accordingly.
Technology & Automation
As you navigate internal operations and create ways to secure documentation for each order, it is incumbent upon you to explore the various ways to use technology in this effort. For example, e-prescribe solutions have dramatically reduced the time and effort required to gather documentation. Several providers said they assist in training the doctors’ offices who sign up for e-prescribe and the outcome is clean, qualified referrals that turn into orders instantaneously and claim submission in a day or two. This can reduce the time from order to billing by seven to 10 days or more.
A win-win solution, applications like this are game changers in this otherwise cumbersome and arduous task. Securing documentation enhances cash flow and eliminates hassle for the referral source. Moreover, gaining access to a hospital’s electronic medical records allows the HME provider to find patient documentation information directly in the doctor’s chart notes. This in turn ensures the patient meets medical necessity qualification.
With digital technology such as texting and portals, you can notify patients and others of required documentation. When you upload insurance cards and other important documents, patients become involved in their care. When an insurance card is missing, the patient can scan it over to you quickly—something that might once have taken a week or more. The outcome: improved device adherence, more knowledge and better utilization.
In summary, documentation has historically been a bottleneck for any HME order and is often the reason a claim is paid or denied. Now more complicated than ever, securing documentation is not just a Medicare and Medicaid issue, it has also become a Medicare Advantage and Managed Medicaid matter.
Monitor MA payer requirements to ensure they uphold traditional Medicare guidelines and nothing more stringent. In working to gather all of this documentation, make sure that staff understands the nuances and particularities of all payers and eligibility is correct at the outset of the order intake process. Eliminate denials and multiple touches by automating processes and informing staff of the requirements upfront. Finally, use technology to inform the documentation you gather and reduce errors, improve cash flow and eliminate referral source hassle factor.
All in all, documentation will never be as simple as it was way back when, but with the technology and advancements mentioned here, it can be seamless and promising for your organization and its bottom-line profit.
