One of our clients has contracted with us to coordinate the benefit verification services of the hotline with Payer Advocacy work for two Biologics. The client requires the GIRS Payer Advocacy Compass (PAC)™ Team to research with the payers why the benefits investigation for the Biologics are denied. Then at a higher level, the PAC Team works to educate the payer on the clinical data if non – coverage is verified.
In a recent case, where one of the Products were not covered, GIRS contacted the payer and found out that the plan considered one of the HCPCS codes to be covered based on clinical review, but the second code was non-covered. We got the plan to agree to review the clinical data by the next review date for the non-covered Product. Upon further research with the plan, GIRS was also able to obtain the names of other PPO and Medicare Advantage plans affiliated with the this payer and the coverage details of the other plans. This helped to educate the Hotline about the coverage details for these plans. It also helped the sales force to track the plans that cover our client’s Products through the coverage database. The client is very happy with the sales force coverage education and the opportunity that they now have with this payer to establish positive coverage for their Product due to our work.