In the summer of 2018, the GIRS Payer Advocacy Compass® team had the opportunity to begin working on a project for a medical nutrition product approved for patients with dysphagia. The manufacturers of the product recently reformulated their product to a more concentrated version which led to inadequate payment under the existing code. As Medicaid is a primary payer for their market, the manufacturer requested that GIRS research the coding, coverage and reimbursement for their new product with the Medicaid programs in order to improve its Medicaid coverage and payment.
Our Decryptase Coding Strategies® team of certified coders conducted coding, billing, and payment research for the concentrated version of the medical nutrition product to determine coding strategies. In addition, ten Medicaid programs which represent key markets for the manufacturer were targeted for primary and secondary research. Equipped with the results of the coding research, the GIRS Value Discovery Landscape Assessments® team then educated the Medicaid programs that were in key markets for our client. Secondary research was also conducted of each payer, and their Medicaid policies, manuals and fee schedules were analyzed extensively. In addition, the most appropriate coding and modifiers for the concentrated product, the process for coverage and payment for the new product and the timelines were all researched with key Medicaid program staff. Within three months, the research resulted in uncovering four Medicaid programs which had favorable reimbursement and three who had seemingly unfavorable reimbursement. We developed strategic recommendations for approaching each Medicaid program.
Unlike with commercial payers, Medicaid program changes are most often met with additional federal and state legislative hurdles, and typically take three to six months (sometimes longer) to take effect. The manufacturer of the product was pleased with the information and, as a result of the GIRS teams’ hard work, agreed to expand the project and extend the work into 2019, in order to obtain more favorable results and increase patient access to their product.
Does your Company have reimbursement issues with your pharmaceuticals, biologics, diagnostics, medical devices, combination products, biosimilars or surgical supplies?
We can help you to obtain positive coverage and appropriate payment by assisting you to meet payer requirements, and by educating the payers about the benefits of your product. Please contact us by email or call us at 1-844-514-4477.
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