DME Prior authorization is a procedure in which a request for provisional affirmation of coverage is filed. It is for consideration prior to the distribution of a medical item to a beneficiary and the submission of a claim for payment. Before supplies are delivered, DME prior authorization makes sure that all applicable coverage, payment, and coding regulations are followed. Despite addressing a rise of global pandemic cases this year, most clinicians still encountered a high DME PA workload, according to the American Medical Association (AMA).

DME Prior authorization accomplishes the following tasks:

  • Confirms that the service is both required and appropriate from a medical standpoint
  • Validates the effectiveness of the member at the time of the requests and service dates
  • Assists healthcare providers in delivering adequate, timely, and cost-effective care
  • Members are directed to the appropriate level of care and service location
  • Determines in advance whether a requested service is eligible, i.e. whether the service is a covered benefit
  • Identifies case/disease management opportunities
  • Ensures that care is delivered in the most appropriate and cost-effective manner

High workload

The American Medical Association (AMA) revealed that 85% of physicians rated the burden of DME prior authorization as high or extremely high last year in a poll of 1,000 practicing physicians. According to the report, practices completed an average of 40 DME prior authorizations per physician every week. On average, those prior authorizations took two business days, or 16 hours, per week.

AMA Findings

Through a partnership of industry participants that devised a strategy for streamlining the administrative process, the AMA has been spearheading an initiative to decrease the load of DME prior permission on physicians. In 2018, a collection of pharmacists, medical groups, hospitals, and health insurance signed a letter of intent to improve DME prior authorizations. According to the AMA findings, Health plans have made little progress in the last three years in implementing changes.

Demand for implementing electronic DME PA

Prior authorization processing time can be reduced from days to minutes by utilizing e- DME PA systems. Digital platforms can pull comprehensive patient coverage findings, including DME prior authorization restrictions, using enhanced benefit verification techniques.

Based on the integration of the product and the patient’s insurance coverage, repopulated questions and response options for the relevant prior authorization request can be pulled. The connection for real-time electronic DME prior authorization filing for more than 80% of payer-covered lives, makes DME prior authorization findings for some medicines can be delivered faster.

Key takeaways

The most important message from these two studies is that the debate over prior authorizations isn’t going away anytime soon. DME Prior authorizations are useful, but data is beginning to suggest that they are a significant administrative burden that should be reduced.

While organizations and corporate health plans are inclined to maintain testing a variety of prior authorization guidelines, clinicians and providers are almost certain to argue that. While efforts to reduce unnecessary medical services are worthwhile, the time-consuming prior authorization process can erode the quality of healthcare and needs to be re-worked.

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