Market access: Aim for external connectivity

Q. We are seeing a significant move toward payers adopting end-to-end DME benefit management. What are the top three things forward-thinking HME owners should do today to ensure they are adapting alongside this important shift?

A: The shift toward end-to-end DME benefit management is being driven by a maturing digital infrastructure, as well as pivotal policies like the CMS Interoperability and Prior Authorization Final Rule. As the industry moves away from antiquated manual processes and a historical reliance on faxing, payers are increasingly prioritizing those who can offer a frictionless, transparent experience within a more integrated, data-rich health care ecosystem.

To ensure your business is adapting alongside this shift, forward-thinking HME owners should focus on these three strategic areas:

Prioritize digitization-first technology solutions

The goal is no longer just internal efficiency; it is external connectivity. HME companies should seek technology solutions that prioritize interoperability via FHIR-based APIs (Fast Healthcare Interoperability Resources), allowing for a seamless exchange of clinical data. By becoming a digital extension of the payer’s workflow, HMEs can reduce administrative friction and position themselves as future-ready with the ability to scale alongside evolving technical requirements.

Solve at the point of order

The industry is moving away from a reactive point-of-claim model, where documentation or qualification gaps are identified only after the service is rendered or the supply is provided. In an end-to-end environment, clinical validation must happen at the point of order. Utilizing e-prescribing platforms or technology solutions that verify clinical eligibility in real-time ensures the referral is complete before the supply or equipment delivers to the patient. This offers a more proactive approach to revenue cycle efforts and ensures better continuity of care for patients.

Leverage performance data as a value proposition

In a managed benefit landscape, data is a powerful differentiator. Forward-thinking HMEs should use their internal metrics – such as clean claim rates, patient adherence, and satisfaction scores – to quantify their impact. By using this data to tell a compelling story to payers, you move beyond being just a supply or equipment provider to becoming a strategic collaborator. Demonstrating a consistent track record of operational excellence makes you a more attractive, low-risk collaborator for payers who are under immense pressure to manage costs while maintaining high standards of patient service.

Yelena Brusilovsky is vice president, commercial sales, for ADSG | Edgepark.