The GIRS Payer Advocacy Compass® (PAC) team began work with a prominent payer in May 2018 to obtain positive coverage and appropriate payment for a breakthrough medical device. GIRS initially considered unknown coverage to be an option for the device as the PAC team could not find a medical policy and the payer was unable to provide coverage details without a member’s policy number.
The GIRS PAC team continued to communicate with the payer and conduct ongoing policy monitoring which, in July 2018, yielded a new coverage policy that had positive coverage for the device with no restrictions. The GIRS PAC team also was able to maintain an ongoing dialogue with the payer’s Chief Medical Officer (CMO) to obtain more specific information about the coverage that is not publicly available. The CMO also referred GIRS to the Director of Health Care Policy who was able to provide additional details about the somewhat ambiguous medical policy. As a result of the payer interactions, the PAC team was able to verify positive coverage, appropriate billing codes, documentation guidelines, covered indications, and other relevant information that would guide our client’s accounts when billing for their product.
As a result of policy monitoring and ongoing discussions, positive coverage with one of the most prominent payers in the Northeast – an important market for our client – was verified for our client’s product. This resulted in an increase in coverage of approximately 5 million covered lives, which represents a potential for market expansion and patient access in this region.
We developed tools to educate the client’s sales force and key stakeholders of the new, positive coverage. We also made strategic recommendations to our client to educate and support the providers to reduce roadblocks in complying with the new medical policy. This improved patient access to our client’s device in this key market. We also emphasized that unless all key stakeholders are educated and the sales force communicates the positive coverage safely to accounts, this positive outcome will not automatically result in improved patient access and market uptake.
If you need expert payer advocacy and policy monitoring, stakeholder and sales force education, or support for your pharmaceuticals, medical devices, biologics, and diagnostics, please contact us and follow our page on LinkedIn.