Tips from Paula: Billing for DME Items

When we are having surgery or other services that are performed by a doctor or hospital,   there are times when medical supplies, also known as Durable Medical Equipment (DME), are dispensed by that doctor or hospital. We should not assume that the doctor or hospital is the actual vendor for those supplies.

For example, if a person has surgery at an outpatient surgical center, they are often sent home with items such as a walker, crutches, or specialty ice packs. We might assume these items will fall under the general bill from the center, along with the other services, such as the surgery itself, surgeon fees, etc.

However, we are finding that surgical centers are not always the actual vendor for many of these DME items. They may dispense them, but the bill for these items will come from a third party. And with that third party billing, there are often problems with coding and coverage once the claim hits the insurance carrier’s claim system. If the provider submits with a code that the claim system doesn’t recognize, the claim will deny.

The vendor may also not be considered “in network”, which, for some plans, can result in higher out of pocket costs for the patient.

Members should be prepared to review their bills and statements from the carrier. They may always dispute this via the appeal process with the carrier, and/or work with the provider to ask them to submit with a code that the insurance company can recognize.