Financial and Billing DME Fact Sheet

Applicable Accreditation Standards

DME Suppliers must implement financial management practices and policies that ensure accurate accounting and billing to insurance companies and patients. This includes maintain:

  1. Accounts that link equipment and/or item(s) to the patient. 
  2. Procedures for identifying and correcting billing discrepancies. 
  3. A charity policy (if applicable). 
  4. A loaner equipment policy. 
  5. Fraud, waste, and abuse policies where required by state law. 
  6. Use of the most current CPT/ICD codes. 

Financial and Billing Policies

Requirements

Written financial management policies must be developed and maintained to ensure accurate accounting and billing to insurance companies and patients. Each policy should outline the procedures, controls, and documentation requirements to ensure adherence to the standards. 

Financial Hardship/Charity Policy

  • Provides assistance to individuals unable to pay due to financial constraints. 
  • Establishes specific eligibility criteria, outlined in policy, to be applied consistently.
  • Describes procedures for application, approval, and denial of charity assistance.

Fraud Waste and Abuse Policy 

  • All supplier employees and management are responsible for preventing, detecting, and reporting abuse.
  • The supplier will comply with all federal, state, and local laws regarding regulations to control FWA.
  • Situations that constitute FWA should be clearly defined.
  • Procedures for reporting identification of suspected FWA should be addressed.

Billing and Discrepancy Resolution Policy

  • Describes procedures necessary to prevent errors prior to billing (e.g., at the time of referral, completion of physician orders, accurate insurance authorizations). 
  • Provides controls for discovering errors and discrepancies before submission to the insurance company (e.g., reviewing claims for completeness, accuracy, and diagnosis codes). 
  • Addresses responses to patient inquiries regarding billing. 

Key Things to Keep In Mind

  • Criteria established for charity must be applied equally and consistently to all patients.
  • Maintaining accurate patient billing records to substantiate claims helps prevent reimbursement denials. 
  • Procedures for reporting or identifying suspected fraud, waste, and abuse (FWA) must be defined in the policy.