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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

The GIRS Value Pointer Outcomes Strategies™ Team can Assist to Develop Payer Desired Clinical and Cost Outcomes for Coverage and Payment!

Posted by on Sep 21, 2017 in Payer Coverage | Comments Off on The GIRS Value Pointer Outcomes Strategies™ Team can Assist to Develop Payer Desired Clinical and Cost Outcomes for Coverage and Payment!

Two radiation oncologists, Eric Ojerholm, MD and Christine Hill-Kayser, MD, at the Roberts Proton Therapy Center of the University of Pennsylvania in Philadelphia, have identified an issue with insurance company reimbursement for Proton Therapy claims. In a study of 287 cases, all of which were classified as pediatric primary tumors, roughly 11% of claims that were initially denied for insurance reimbursement were later approved upon appeal. According to Dr. Ojerholm, and Dr. Hill-Kayser, this process is stressful and inefficient. In their case study of 287 primary pediatric tumors from 2010 to 2015, the appeals process for an initially denied insurance claim for proton beam therapy (PBT) took an average of 7.5 days, and included a combination of letters and telephone calls. In pediatric cases especially, time is always of the essence in treatment options. Therefore, this delay in coverage is placing unnecessary stress on families who are already in crisis. Of the cases submitted for reimbursement, 59% were primary Central Nervous System (CNS) tumors, 29% were non-CNS tumors, and 12% were non-CNS lymphomas. 88% of the patients were younger than 18-years-old, and 12% were ages 19 to 30. The primary reason for the denials by the insurance companies is a lack of proven efficacy of proton therapy. For this reason, some physicians and researchers...

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Let GIRS Assist you to Analyze the Impact of the 2018 Medicare Inpatient Rehabilitation Facilities Payment and Policy Changes

Posted by on Sep 18, 2017 in News | Comments Off on Let GIRS Assist you to Analyze the Impact of the 2018 Medicare Inpatient Rehabilitation Facilities Payment and Policy Changes

On July 31, 2017, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the 2018 payment and policy changes for Medicare Inpatient Rehabilitation Facilities (IRF.) The changes to be expected from this rule include updates to IRF Prospective Payment System (PPS) rates, removal of 25% payment penalties for late transmissions, adjustments to the 60% rule of presumptive methodology, technical process revisions, and the IRF Quality Reporting Program. In the following, we review each of these changes in more detail. Updates to IRF PPS rates: IRS PPS rates will reflect a 1% increase factor, in addition to an approximate 0.1% decrease to aggregate payments. Removal of 25% Payment Penalties: IRF PPS rates currently invoke a 25% payment penalty on transmissions that are not submitted in a timely manner. These penalties will no longer apply beginning FY 2018. Adjustments to the 60% Rule of Presumptive Methodology: In order to obtain, and retain, classification as an Inpatient Rehabilitation Facility under Medicare and Medicaid guidelines, a 75% threshold compliance standard was adopted on May 7, 2004. This rule stipulated that “a minimum percentage of a facility’s total inpatient population must require treatment in an IRF for one or more of 13 medical conditions listed in 42 CFR 412.29(b)(2).” Beginning July 1, 2006, this rule...

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CMS Releases Proposed Changes to Hospital Outpatient Prospective Payment System for 2018

Posted by on Jul 18, 2017 in Future Trends, Payment System | Comments Off on CMS Releases Proposed Changes to Hospital Outpatient Prospective Payment System for 2018

On July 13, 2017, the Centers for Medicare and Medicaid Services (CMS) issued the CY 2018 proposed changes to the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1678-P). We discuss the proposed changes for the OPPS in this blog. These proposed changes would affect care delivery, drug costs, beneficiary out of pocket cost for several drugs and providers in rural areas. Additionally, CMS is also releasing a Request for Information to...

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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...

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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...

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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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