Why DME Claims Are Different
DME claims require more than a cursory review. They demand validation across multiple dimensions:
- Is the equipment clinically appropriate for the patient’s condition?
- Does the claim align with the member’s benefit design and CMS guidelines?
- Are modifiers, HCPCS codes, other coding elements, and documentation correct?
Failure to address these questions can lead to improper payments, regulatory penalties, and downstream member dissatisfaction.
Understanding the Risk
Fraudulent billing for DME is a persistent issue. Common schemes include:
- Billing for equipment never delivered
- Upcoding to more expensive items
- Submitting claims without required physician documentation
Without robust edits, these claims slip through, inflating costs and undermining compliance efforts.
Why Zelis DME Edits Are Different
Many vendors offer DME edits, but not all edits are created equal. Here’s what sets Zelis apart :
1. Depth of Clinical Validation
Our edits go beyond surface-level checks. We validate against CMS guidelines, Local Coverage Determinations (LCDs), and proprietary clinical logic. This helps align claims with applicable regulatory and clinical standards.
2. Dynamic Rule Engine
Healthcare policy evolves constantly. Zelis edits are updated continuously to reflect new CMS guidance, LCD updates, and payer-specific requirements, helping ensure edits remain aligned to current standards.
3. Granular Modifier Analysis
Modifier misuse is one of the leading causes of improper DME billing. Zelis uses advanced logic to identify missing, invalid, or conflicting modifiers that often get overlooked in traditional solutions.
4. Proven Results
Health plans using Zelis DME edits are seeing measurable impact:
- Roughly 15% of reviewed claims result in a denial recommendation
- Average savings of $399 per claim edited
These results reflect real outcomes — not theoretical savings.
Built to Work the Way You Do
Zelis DME edits are designed to fit into existing operations, not disrupt them.
- Workflow integration: Our DME edits can be deployed with minimal IT or admin burden, helping plans get the most of their cost containment strategy
- Configurable logic: We tailor edits to plan-specific policies, reducing false positives and manual rework
- Actionable insights: We don’t only provide quality recommendations, we provide visibility into denial trends, helping plans adjust policies and educate providers proactively
Where Other Solutions Fall Short
Many DME edit solutions leave critical gaps:
- They focus on HCPCS validation but miss clinical context
- They rely on static rules that lag behind CMS updates
- They offer little transparency into why a claim was flagged
Zelis closes these gaps with clear logic, continuous updates and clinically sound edits that stand up to provider review and appeal.
Questions Every Payer Should Ask
Before choosing a DME edit solution, health plans should ask:
- Does it validate against both CMS and LCD guidelines?
- How often are rules updated?
- Will it integrate smoothly with existing workflows?
- Does it provide actionable insights beyond claim edits?
If those answers aren’t clear — or confident — risk may already be creeping in.
The Bottom Line
DME claims aren’t just another line item. They’re a high-risk area that demands accuracy, adaptability and clinical rigor.
Zelis delivers that precision with dynamically updated, clinically validated DME edits that help health plans reduce improper payments, strengthen compliance and protect the member experience.
Connect with Zelis to see how our DME Edit Suite helps you improve claim accuracy, manage risk with confidence, and deliver better outcomes for your members.
