Home Health & Hospice Week

Ever feel like you can't catch a break? According to one durable medical equipment regional carrier, DME suppliers continue to make the same mistakes over and over again. So if the same problems keep cropping up all the time, it might be time to look at your bad habits and try to mend your ways.

Region B DMERC Adminastar Federal has issued in its latest supplier update a list of the top five problems that lead to claim submission errors. Adminastar bases the list on an analysis of claims from October to December 2002. According to the DMERC, the five most common billing sins are:

1) Duplicate claims. This accounted for around 354,693 claims during the previous quarter. You can avoid this error by letting at least 14 days pass before resubmitting a claim electronically or at least 28 days before resubmitting a hardcopy claim. Also, you can use the claim status inquiry (CSI) system to find out the status of claims, Adminastar says.

Whenever the DMERCs issue their billing errors, duplicate claims always ranks at the top, says consultant Lisa Thomas-Payne with Medical Reimbursement Systems in Albuquerque, NM. The volume of duplicate claims has gone down over the years, but it still tops the list every time.

In fact, there are three kinds of duplicate claims, says Thomas-Payne - supplier errors, DMERC errors and system errors. Supplier errors occur when a supplier resubmits claims to the DMERCs when a claim is already in process or has been denied for a reason that requires the supplier to request a review. DMERCs often use "duplicate claims" as a dumping ground for all the claims they deny due to a number of different denial codes, which they lump together.

System errors can include common working file edits and DMERC data, such as the fact that a patient has switched suppliers and has an existing rental with the previous supplier. A supplier may not be able to find out this information before submitting a claim, and the DMERCs can't release that information before the supplier submits a claim.

2) No certificate of medical necessity on file. This error, which accounted for around 52,561 claims, happens because suppliers fail to make sure they submit a required CMN with a patient's first claim. They also fail to make sure they fill out all the required information on the CMN. And suppliers need to wait 24 to 48 hours before submitting any subsequent claims, the DMERC insists.

Some suppliers may still be submitting claims without CMNs, Thomas-Payne concedes. But that's probably pretty rare in today's world.

Rather, suppliers may be submitting CMNs where some data field, such as date of service, fails to match what the DMERC already has in its system. This may come up when a capped rental patient switches suppliers and the DMERC already has a CMN record for that patient and product on file. The supplier has a hard time matching up the initial and recertification dates with what the DMERC already has.

3) Invalid procedure codes or rates. Some 43,368 claims went awry because suppliers didn't check the common procedural coding system to make sure they used the correct code to describe a procedure that a patient had undergone, or they listed the wrong rate for that code. Procedure codes are published and easily accessible, so there's no excuse for suppliers to fail to submit the correct ones, says Thomas-Payne. Suppliers need to maintain their internal databases, which form the basis for data they submit to the DMERCs.

4) Wrong insurance carrier. Another 42,210 claims went down in flames because a patient had another insurance carrier that should be primary over Medicare. Always make sure the patient doesn't have other insurance before billing Medicare, the DMERC warns.

There's no fool-proof way to know for sure if a patient has insurance besides Medicare, Thomas-Payne warns, but you can do a better job of screening patients for non-Medicare coverage when you admit them to your service.

5) Wrong region. And 33,846 claims met their doom because suppliers failed to check with the patient to make sure they had the patient's most current main address on file. As a result, suppliers sent claims to the wrong DMERC.

When the DMERCs first came into existence, a patient's home was defined as the place she spent six months or more each year, Thomas-Payne recalls. But now patients are more mobile and the fact that a single DMERC retains a patient's record may cause needless denials.