Using Medicare Accreditation to Make a Difference with Private Pay Insurance

Providers need accreditation to bill Medicare, but it's critical in HME businesses' overall market strategy for working with private payers, as well. What do providers need to keep in mind?

Providers are now largely accustomed to obtaining Medicare accreditation, whether it’s through general or specialized programs designed for specific product categories. But it’s now becoming clear that private payers are taking accreditation just as seriously, making the achievement even more important to a provider’s overall market strategy.

The accreditation process requires passing the inspection of an accrediting organization, which examines a provider’s policies regarding equipment handling, claims documentation and patient satisfaction as well as the implementation of those procedures. Once a provider earns accreditation, referral partners and payers have outside confirmation that the organization is laser-focused on meeting industry standards and improving patient outcomes.

Many private pay insurance companies have come to expect accreditation from providers, making it imperative to obtain the recognition even if the HME/DME business does not frequently bill Medicare for DMEPOS claims. Over the past few years, private payers have gone a step further and started to concern themselves with the specific categories that providers are accredited in, whether that’s oxygen concentrators, manual wheelchairs or another sector.

The increased scrutiny on accreditation opens opportunities for HMEs to stand out from the crowd.


Over the course of the several decades after the Medicare accreditation requirement was introduced, private payers largely went along with the requirement but were not as interested in zeroing in on what HME providers were accredited for. That element of the equation has changed in recent years, as more accrediting organizations have introduced specialized programs that allow providers to showcase their expertise in specific product categories, including respiratory health, pharmacy, home infusion and sleep therapy.

With the growth in popularity of those programs, it’s no shock that private payers have caught on and will be more likely to reward providers that have taken the time and energy to specialize in the most important areas of their business. This mindset acknowledges that there are major differences in setting up a home infusion program and providing a patient with a manual wheelchair.

The trend may take on increased importance as insurance companies look for providers that have infection control and emergency policies in place to handle a second or third wave of the COVID-19 pandemic. If an HME provider can show that their personnel have been trained to handle emergencies and can effectively manage risks to both staff and customers, that provider will have a major leg up on the competition regardless of product category.

What else are private payers looking for that they may not have in the past? Private insurers are particularly concerned with quality improvement plans and patient experience policies. While these may come off as buzzwords within the HME industry, their impact is quite real.

Providers that highlight their working quality improvement plans and show they are continuously looking at areas of their company to enhance will have a much easier time convincing private payers of their concern for compliance. Plus, these providers will be better prepared to handle whatever emergency or unforeseen circumstances come down the pipe – a characteristic that will carry even more weight as the healthcare system weathers the storm of COVID-19.


To navigate the at-times rough waters of accreditation, providers must first seek out an accrediting organization that fits their needs. For a successful experience, providers should not choose accreditors that appear to give a quick stamp of approval but instead find organizations that will prepare the business for the long haul.

Leaders should ask if the accreditor offers additional educational elements or has shown the willingness to continuously update their providers on changes in the medical equipment landscape. Providers should reach out to their networks in the industry and ask about their experiences with the accrediting organizations, particularly if they also work in similar product and care categories.

From there, providers can decide if pursuing specialized accreditation makes sense for the long-term growth and reputation of their businesses. If so, they must choose an accreditor that offers a program in that sector and can guide them through the compliance and inspection process. The organization should provide the all-inclusive cost of the program so that providers know how much time, money and effort will be spent on the process.

It’s also important that providers consider if the requirements of the accreditor fit their business size, particularly if their programs were designed for larger companies. Quality standards are the same for every business, but a 10-location provider could be burdened by the process if they are treated like a 100-location provider.


Once a provider has committed to the time and effort required to obtain specialized accreditation, they can start to reap the benefits of that investment. In particular, private payers have been impressed by programs like The Compliance Team’s Patient-Centered Respiratory Home, a program designed to help advanced respiratory care providers perform at the top of their license and better serve patients.

Advanced pharmacy accreditation programs have also seen their value grow, as providers show that the high quality of their business could help the payer’s bottom line. If a provider can keep patients satisified, compliant with their therapy regimens, and prevent emergency room visits or readmissions, insurers will no longer have to pay for the patient to have costly hospital care on a regular basis.

Rather than making these cost-savings and patient satisfaction arguments in a silo, accreditation brings outside validation to the provider’s claims when seeking contracts with private payers, skilled nursing facilities and ACOs. To get these valuable contracts, providers have to be willing to go the extra mile, and specialized accreditation is increasingly part of that calculation.


  • After years of largely accepting the accreditation requirement, private payers have begun to scrutinize what product categories providers are accredited for when making decisions about valuable contracts.
  • As the HME industry weathers the storm of the COVID-19 pandemic, demonstrating compliance and emergency preparedness policies to private payers will become more crucial in standing out in the marketplace.
  • Accrediting organizations have created programs specifically targeted at proving expertise in product categories such as oxygen, home infusion, pharmacy and more.
  • Choosing an accreditor for specialized accreditation or a robust general accreditation program comes down to the best fit as well as the educational content and industry updates that an accreditor can provide.


To learn more about how to get the most of your accreditation for Medicare and private payers, check out the HME Business Accreditation Solutions Center.

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