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Welcome to Global Integrated Reimbursement Services’ blog. The purpose of our blog is to allow access to a repository of issues that our company tracks regarding the reimbursement for pharmaceuticals, medical devices, diagnostics, biologics, and biosimilars. Also, it shows you how we can assist you in these areas.

Most Recent Articles

UnitedHealth Group to Implement Bundled Payment Models

Posted by on Dec 21, 2016 in Payer Coverage, Payment System | Comments Off on UnitedHealth Group to Implement Bundled Payment Models

UnitedHealthcare, a subsidiary of UnitedHealth Group, followed in the Centers for Medicare & Medicaid Services (CMS)’s footstep by recently announcing that they would be adopting bundled payment models for spinal surgeries, hip and knee replacement surgeries in over 40 markets next year. When it comes to knee replacement and hip surgeries, some payors have seen a great increase in prices. To lower overall healthcare spending and improve care, CMS, the largest payor in the country, implemented the Comprehensive Care for Joint Replacement (CJR), a bundled payment model pilot for hip and knee replacements. “This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.” (CMS, December 2016). Traditionally, payors make separate payments to providers for each of the individual services they furnish to a patient for a single illness or episode of care. This fee-for-service approach “can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished.” (CMS, December 2016). Under a bundled payment model, all providers involved—including the physician, post-acute care...

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Elimination of Medicare Appeals Backlog Ordered by 2020

Posted by on Dec 20, 2016 in Payer Coverage, Payment System | Comments Off on Elimination of Medicare Appeals Backlog Ordered by 2020

A federal judge recently decided that the Secretary of Health and Human Services (HHS) must eliminate the Medicare appeals backlog currently pending before Administrative Law Judges (ALJs) by Dec. 31, 2020. An appeal is the action a Medicare beneficiary or healthcare provider can take if they disagree with a coverage or payment decision made by Medicare, a Medicare health plan, or a Medicare Prescription Drug Plan. The appeals process has 5 levels; If one disagrees with the decision made at any level of the process, they can generally go to the next level. Once a level 3 appeal is filed with the ALJs, by law, the court has 90 days to make a decision. Over the past several years, those level 3 reviews have become increasingly delayed due to volume. HHS reported that appeal hearings at the ALJ level were now, on average, held for 935.4 days, which is over ten times greater than the 90-day statutory limit. The court’s ruling is a victory the lead plaintiff, the American Hospital Association (AHA), and three of its member hospitals who have long contested HHS’s failure to render ALJ decisions within the prescribed statutory deadline. “Today’s decision is a victory for hospitals that continue to have billions of dollars in Medicare reimbursement tied up in a...

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Evidence Review Conducted by the GIRS Value Pointer Clinical Outcomes Strategies Team Sets the Stage for 2017 Payer Advocacy Strategies

Posted by on Dec 14, 2016 in Payer Coverage | Comments Off on Evidence Review Conducted by the GIRS Value Pointer Clinical Outcomes Strategies Team Sets the Stage for 2017 Payer Advocacy Strategies

  The GIRS Value Pointer Clinical Outcomes Strategies™ Team conducted an evidence review for a drug that resulted in integrated clinical outcomes and reimbursement strategies.  We performed a literature search for the class of drug and reviewed six studies.  Four of the studies were Randomized Control Trials (RCTs) and two were prospective clinical studies.  Three studies were based in Europe and three were conducted in the U.S.  This review resulted in two main studies being selected for the Evidence Table...

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Medicare Part B Policy Change for Discarded Drugs and Biologics for 2017

Posted by on Dec 12, 2016 in Coding & Billing | Comments Off on Medicare Part B Policy Change for Discarded Drugs and Biologics for 2017

  In addition to paying for the amount of drug that has been administered to a Medicare patient/beneficiary, Medicare Part B also reimburses the amount of discarded drug, up to the amount on the package label. The discarded drug amount is the amount of a single use vial or other single use package that remains after administering a dose/quantity of the drug to a Medicare beneficiary. Effective Jan. 1, 2017, the Center for Medicare and Medicaid Services (CMS) will...

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CMS Delays the Inclusion of U.S. Territories Under MDRP Until 2020

Posted by on Dec 9, 2016 in Future Trends, Payer Coverage | Comments Off on CMS Delays the Inclusion of U.S. Territories Under MDRP Until 2020

The Center for Medicare and Medicaid Services (CMS) released an interim final rule (IFR), Medicaid Program; Covered Outpatient Drugs; Final Rule. The Rule delays the expansion of the Medicaid Drug Rebate Program (MDRP) to Puerto Rico and the U.S. Territories (collectively, “Territories”) for three years, until April 1, 2020. The inclusion of U.S. Territories under the MDRP has been delayed to account for the need for more time and the complexity of the transition for both the Territories and...

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WellCare Expands Medicaid Market with Care1st Acquisition

Posted by on Dec 7, 2016 in Payer Coverage | Comments Off on WellCare Expands Medicaid Market with Care1st Acquisition

WellCare Health Plans Inc. announced its intentions to buy Care1st Health Plan of Arizona, an Arizona Medicaid Managed Care plan, for $157.5 million. As of now, more than half of WellCare’s 2.43 million Medicaid members reside in Florida and Georgia, states that have not expanded Medicaid under the Affordable Care Act (ACA). This deal will allow WellCare “an opportunity to expand our footprint into Arizona’s growing Medicaid and Medicare markets,” said Ken Burdick, WellCare’s chief executive officer. The deal...

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GIRS’ Six Tips for Successfully Adopting a Medical Technology Contact Support Center

Posted by on Nov 16, 2016 in Hotline Successes | Comments Off on GIRS’ Six Tips for Successfully Adopting a Medical Technology Contact Support Center

Within constantly changing payer landscapes and payer requirements, a reimbursement hotline staffed with dedicated reimbursement experts bridges the gap between providers, manufacturers, and payers. Such a dedicated reimbursement team can play an invaluable role to educate providers on submitting clean claims, appealing denials of coverage and payment, as well as other payer requirements. Selecting such an expert team to help providers stay informed of your Product’s coding, billing, and coverage requires careful consideration. The following is a list of...

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