DME Case Study
Fewer Same-or-Similar Denials on Medicare DME Claims
Medicare DME billing | Same-or-similar checks, claim accuracy and order verificationThe challenge
A supplier of respiratory, mobility and home medical equipment kept getting same-or-similar denials from Medicare. These happen when the patient already has a comparable item that’s still within its reasonable useful lifetime, which is generally at least five years from delivery.
Some orders were true replacements or reflected a change in the patient’s condition, but the file didn’t show it. Others were simply billed without anyone checking the patient’s equipment history first. Every denial meant a redetermination request or a write-off, and a long wait for payment.
What we did
- Ran a same-or-similar check in the DME MAC portal, along with eligibility, before each Medicare claim went out.
- Asked the supplier to confirm with the patient or caregiver whether they’d received similar equipment before.
- Where a conflict showed up, checked whether the file supported a covered exception: loss, theft, irreparable damage, or a change in condition that supports a different item.
- Reviewed HCPCS codes, repair records and continued need and use documentation against the order.
- Sent missing items back to the supplier’s intake team and held the claim until they came in.
- Kept a running log of repeat issues so intake could fix them at the source.
Results
| Metric | Before | After | Improvement |
|---|---|---|---|
| Claims flagged for same-or-similar issues (per month) | 120 | 30 | 75% reduction |
| Preventable same-or-similar denials (per month) | 45 | 12 | 73.3% reduction |
| Claims needing additional review (per month) | 180 | 45 | 75% reduction |
| Average time to resolve a flagged claim | 18 days | 5 days | 72% faster |
What changed
Flagged claims fell by 75% and preventable denials by about 73%, mostly because intake started asking about prior equipment up front. The average time to resolve a flagged claim was cut from 18 days to 5 days.
A flagged claim isn’t always ineligible, and not every same-or-similar denial can be prevented.
Takeaway
The cheapest same-or-similar denial to fix is the one that never gets billed. Check equipment history before the claim, not after the remittance.
Seeing same-or-similar denials? Request a free billing audit.
How Salyx RCM helps DME suppliers
Same-or-similar conflicts, unchecked payments and delivery-to-billing delays are three of the most common places DME suppliers lose time and cash. We work on the billing side of all three.
- DME and respiratory billing
- CPAP billing and recurring supplies
- AR follow-up and denial management
- Payment posting and ERA/EOB reconciliation
- Eligibility checks and prior authorization
- Documentation follow-up and claim readiness
- Revenue cycle reporting
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