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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.

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...

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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...

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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 to be included in the payer dossier for coverage.  These studies were selected because they met payer desired criteria for study design and evaluated the drug in the target population. The remaining four studies were not selected because they did not evaluate the medical therapy in the target population.  It is unlikely that payers would consider these four studies generalizable...

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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 require uniform use of the JW modifier for Part B drugs or biologicals from single use vials or single use packages.   Under this policy change, providers and suppliers will be required to: Use the JW modifier when submitting Part B claims for discarded drug or biological amount not administered to any patient, except for Competitive Acquisition Program (CAP) drugs and...

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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 manufacturers. Unless granted a waiver, this expansion will require the U.S. Territories to participate in the MDRP, and also will require participating manufacturers to include sales to customers located in the Territories in their calculations of average manufacturer price (“AMP”) and Best Price. This expansion means that participating manufacturers will likely pay rebates to Territories and include sales to customers...

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