Case Study 1: DME Client Develops a Successful Solution for a Reassigned Product Code
GIRS submitted a coding verification for a DME client in 2008. In 2015, the Pricing, Data Analysis and Coding (PDAC) contractor reviewed its own decision and reassigned the Product to a non-covered product code. With the assistance of our reimbursement lawyer, the decision was appealed, and we were able to develop a solution that helped our client.
Case Study 2: Biologic Client Educates Stakeholder about a Product Coding Change
The Centers for Medicare & Medicaid Services (CMS) reassigned a category of Biologics from J codes to a Q code to track its use. GIRS was aware that this change was impending from discussions with the Medicare Administrative Contractors (MACs). The client was advised about the impending change, the Billing Guides were modified to reflect the changes and providers were educated on an ongoing basis. With payer education about the coding changes, coverage continued, and the coverage policies were updated by the payers appropriately.
Case 3: Delayed Coding Research Leads to Loss of Opportunities with Telehealth Expansion
The leadership of a telehealth company discussed the possibility of identifying the most appropriate codes for their tracking technology with GIRS several times since 2019. They were misguided by another consultant to apply for transitional pass–through coding but the Product did not qualify for it. This experience discouraged the company from seeking any further reimbursement consulting support.
GIRS proposed a Reimbursement Landscape Assessment to identify the most appropriate short-term and long-term coding strategies, payer market strategies and proposed a Billing Guide. The company decided that the best way to identify the appropriate codes was to follow provider billing practices and to see what claims were paid.
GIRS explained the importance of working with an expert reimbursement consulting firm to create foundation strategies for their Product. GIRS also advised the company on the importance of drafting a Billing Guide with appropriate notices and disclaimers and having the document reviewed by a reimbursement lawyer and their internal legal counsel before disseminating coding advice.
As a result of not doing the much-needed work in 2019, during the 2020 pandemic, this company lost the opportunity to take advantage of the telehealth expansion as they were not sure of the codes.
However, the company is now considering doing the proposed reimbursement work with GIRS.
We are currently offering a free Reimbursement Needs Review to address market access and uptake during the pandemic. Please connect with us in LinkedIn and follow our company page.
About GIRS
For more than 17 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.
