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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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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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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 is expected to close in early 2017. “Care1st Arizona is a well-regarded, quality health plan that has served government-sponsored programs in Arizona for more than 13 years. Its focus on community-based relationships and integrated delivery of medical care and social services aligns with our approach to providing improved health outcomes for low-income families, children, the disabled, seniors and individuals with...

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GIRS Tracks Impact of Health Insurer Mergers on Patient Access to your Medical Technologies

Posted by on Oct 20, 2016 in Payer Coverage | Comments Off on GIRS Tracks Impact of Health Insurer Mergers on Patient Access to your Medical Technologies

Global Integrated Reimbursement Services, Inc. (GIRS) tracks major insurer mergers including the Anthem and Cigna Corp mergers that was blocked by the U.S. Department of Justice. See our LinkedIn Page for more details. However, insurers are now also considering merging with healthcare delivery systems. One such case of a merger that we are tracking is that of Ardent Health Services (“Ardent”) and LHP Hospital Group, Inc. (“LHP”). The companies jointly announced on Wednesday, October 5th, 2016 that they have entered into a definitive merger agreement under which the operations of the two companies will be combined if the merger goes through. Ardent will remain headquartered in Nashville and will assume management and operation of LHP through the guidance of LHP executives. Ardent will remain headquartered in Nashville and will assume management and operation of LHP through the guidance of...

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