Last week, HME News hosted the webinar Mastering Reimbursement: Challenges, Solutions, and Metrics That Matter, featuring Joey Graham, CEO of Prochant, and Andrea Stark, Owner of MiraVista. The conversation continued the important dialogue they started at MedTrade, diving deeper into why reimbursement challenges are critical for HME providers to master. As Joey and Andrea emphasized, reimbursement is the most important factor in a provider’s business success — and when issues aren’t addressed, it stunts growth and cash flow.
They narrowed the discussion down to four major reimbursement challenges that providers face today: generating clean claims, managing denials and audits, improving training and onboarding and avoiding PTAN deactivation.
Generating Clean Claims
The first challenge discussed was generating clean claims. Joey explained that the “holy grail” of revenue cycle management is getting claims right the first time. The best denial, he said, is the one that never happens. Rushing through intake or billing leads to more problems later; instead, providers need to slow down and focus on accuracy upfront. Although this might feel slower at first, it results in faster payments overall and fewer delays.
To set a strong foundation, providers should build clean claim processes into their billing systems. Joey recommended applying the 80/20 rule — focusing on the top 20% of payers that account for 80% of revenue — to create efficiencies and simplify workflows. With strong monitoring systems and a disciplined approach, providers can substantially improve their clean claim rates and prevent downstream denials.
Managing Denials, Audits, and Appeals
Denials, audits and appeals were another major area of concern. Denials can quickly overwhelm teams if not managed proactively. The speakers recommended implementing a “zero-day denial” strategy: every day, export the previous day’s denials, group them by payer and denial code, sort by balance size and work them in order to resolve denials by the end of the day. This daily discipline can prevent backlog and cash flow disruption.
Andrea emphasized the need to understand the nuances of each payer’s appeal processes. Medicare Advantage, for example, has unique protocols like the 90-Day Transition Rule and strict ABN requirements. Providers must follow each payer’s specific procedures carefully to succeed in overturning denials. Having a strong process in place and educating your team on these nuances is critical to staying ahead.
Training and Onboarding
Training and onboarding were called out as often-overlooked areas that have a huge impact on reimbursement outcomes. When bringing new team members on board, providers must tailor their training depending on experience levels — whether they are beginners or more seasoned billers. Joey suggested using AI to build decision trees and create structured curriculums specific to each role.
They added that payer rules are constantly changing, making it necessary for providers to assign an internal “owner” to each payer relationship. That person should subscribe to the payer’s updates, educational listserves and be responsible for keeping the team informed. Easy-to-access, role-specific training materials help ensure consistency and speed up onboarding timelines, while reducing errors and rework down the line.
Avoiding PTAN Deactivation
Finally, Andrea turned the conversation to PTAN deactivation — a risk that is becoming increasingly common. She warned that what used to be a rare occurrence is now a frequent and serious threat to HME providers. Losing your billing privileges due to a PTAN deactivation can cripple your business operations.
To avoid this, providers need to be extremely diligent about monitoring their Medicare enrollment information. Andrea recommended logging into PECOS every six months to thoroughly review and update records. Revalidation dates must be monitored carefully. If a deactivation does occur, providers should seek outside assistance immediately to navigate the complicated reactivation process and minimize downtime.
Takeaways
Joey and Andrea wrapped up the session by encouraging providers to take action. Focusing on generating clean claims, implementing strong denial management strategies, building a thoughtful training program and proactively protecting billing privileges are all critical steps. By mastering these key areas, HME providers can protect their cash flow, support growth and set the stage for long-term success.
To watch the webinar recap, click here.
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