Assessing Patient Eligibility for Insurance Payments

by | February 25, 2021 | 3:53 pm

According to one report, the US DME market size was valued at $52.9 billion in 2020. This is expected to expand at a compound annual growth rate of 6% over the forecast period from 2021 to 2028.

As DME/HME businesses settle into a year of rebuilding and recovery, while continuing contactless transactions, it is time to review and assess business processes, including patient eligibility in insurance.

For a startup DME/HME, there is often a difficult decision between attending to medical requirements and completing diligent record-keeping.

Importance of patient eligibility verification

DME/HME businesses almost always get paid based on the success of claim processing. Any information that is incorrect or incomplete can lead to a claim delay or denial.

Claim denials hurt the billing process. If they are delayed, the DME/HME may have little choice but to write them off. To prevent these issues, eligibility verification is a critical first-step. It assists in assuring successful claim processing and payment collection for the DME/HME.

Insurance elements that require assessment include: co-pay, out-of-network benefits, medical authorization for a particular therapy, line of treatment, medical equipment, among others. An accurate assessment of insurance coverage and benefits, and ultimately, the patient’s ability to pay for healthcare, contributes to a successful claim application. Verification of patient eligibility is also vital to ensure claims that are sent for processing are accurate and required. This avoids needless appeals, resubmitting, and denials. It is worth remembering that denials and appeals are costly, time-consuming, and lead to erosion of patient trust, ultimately affecting business sustainability.

Verifying eligibility

  • Review and verify coverage details, including patient or member ID, group ID (if applicable), co-insurance details, co-pay information, details on deductible, etc.
  • Contact and communicate with patient to review information that seems incomplete or missing.
  • Utilize tools for error-free, reliable patient eligibility verification.

Prior authorization

  • Review the information received from the patient and identify prior authorization requirements.
  • Gather all the information and prepare the paperwork to submit to the payer.
  • Review and conduct follow-through for submitted prior-authorizations. Prepare to communicate with the patient to discuss errors or issues identified.

Ensuring accuracy and timeliness

If you don’t take advantage of skilled professional assistance in eligibility verification, it is possible that the DME/HME may suffer from eroded patient trust and lost payments. This can lead to a concern over business sustainability. Patient eligibility is a critical function and one which contributes in a major way to DME/HME payment for patient services. However, understanding eligibility is both time and attention-intensive. Many small to mid-size DME/HME businesses must multi-task throughout the day. This makes it difficult to ensure a patient’s insurance coverage and payment method is verified. Moreover, the people who operate a DME/HME are not trained to deal with the details associated with insurance documents, or the way in which patient information ties-in with business billing.

Businesses that outsource DME billing — or use professional billing assistance — enable their employees to continue to focus on delivering healthcare to current and new customers while billing intricacies are managed. Outsourced medical billing services can be cost-effective as well, because they not only complete eligibility verification, but streamline the revenue cycle management process overall, which in turn increases collections.

Next Steps

  • A DME partnership can provide the right assistance and expertise to reliably manage DME/HME billing requirements, including data management. The business can continue to focus on providing quality healthcare. Learn more about our medical billing and RCM services.
  • Email us at or call 781.503.9000 for a free session.
  • Engage with us on LinkedIn and Twitter.