The Issue: In November 2019, our client was not receiving coverage for a complex medical supply in a key Medicaid market. The product design had changed, and the old pricing was not appropriate for the redesigned product. In addition, the coding was not representing the redesigned product and there were several coding options that needed to be verified with each Medicaid program to advise accounts appropriately. This Product also can be covered under medical benefits, pharmacy benefits, or DME benefits. The client partnered with the GIRS Payer Advocacy® (PAC) team to work with this payer.
What did we do? GIRS conducted research and strategized the work. In 2020, GIRS worked with the payer and educated them about the Product and issues and the client and provider needs. As a result of the secondary research and direct work with payer decision makers, worked with the payer the client’s product was covered, and the billing code was included in the fee schedule with appropriate pricing. It was verified that prior authorization was required for payment and appropriate guidelines were developed to educate accounts based on payer guidance. In addition, the settings of care for the product, and the age restrictions for the product were verified to guide the sales force and accounts.
Finally, the GIRS PAC team in 2021 found that the fee schedule had a low rate. So, the team worked with the payer to request appropriate payment. Specifically, the GIRS PAC team obtained a favorable payment decision from the payer that their client’s product would be covered above the rate specified in the fee schedule, as long as it was submitted by a provider with their usual and customary rate (UCR). The payer would reimburse at 50% of the MSRP or UCR submitted by providers for payment. Additionally, the payer apologized for the code being an outlier that they did not reprice yet and agreed that repricing this code in the future was a priority. These details were explained to our client’s sales force and marketing teams so that they could understand the opportunities in this payer market for their accounts. The client was encouraged to report any billing and payment issues to the GIRS team so that we could continue to work with the payer to ensure that the claims were appropriately paid.
Thanks to the diligence of the GIRS PAC team, our client was able to receive a clear payer guidance for documentation and necessary next steps required for prior authorization so that claims are paid on time. The cooperation of the payer to reprice the code allow interim payment based on MSRP allowed for a higher rate of reimbursement despite a misleading fee schedule at the beginning.
Are your accounts having difficulty in gaining coverage and the rate you need? Do you keep experiencing denials on claims because of incorrect or insufficient documentation? Do you want to experience similar success working with payers? Let the GIRS PAC team help you get the information you need as we have with our previous success cases.
For more information on our PAC team’s methodology or assistance in a similar situation, email us at info@girsinc.com or call us at 901-834-9119.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
About GIRS
For more than 19 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.