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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.

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 have been found to side with the insurance companies regarding approvals for this particular treatment, claiming that it has always been highly controversial. To date, only one study, on lung cancer, has final efficacy results, and proton therapy was not found to be more effective than the current, standard protocol. Therefore, insurance denials have continued, with no movement by the insurance companies towards creating a more streamlined process for filing these claims.

At the end of Dr. Ojerholm and Dr. Hill-Kayser’s study, 286 of the 287 were approved for proton therapy.

If your drug, medical devices, biologic or diagnostic is experiencing denials of coverage and payment, our Value Pointer Outcomes Strategies™ team consisting of outcomes experts can review your clinical outcomes strategies and studies and help design payer designed studies for coverage and payment. We can assist you to develop the Value Proposition for oayer coverage and innovative contracting. Through our InContact Reimbursement Hotline™, our dedicated reimbursement team can play an invaluable role to assist in appealing denials of coverage. Contact us so that we can assist you and your accounts today to obtain coverage and appropriate payment.