A Durable Medical Equipment (DME) manufacturer who is a long term and repeat client hired GIRS because providers were getting Medicaid denials for their re-designed Product. The reimbursement for the existing code did not adequately represent the cost of the new product. The client also wanted to know if there were any age restrictions for the Product, the settings of care and the types of providers who could bill for the Product.
This case describes the work performed by GIRS and one State Medicaid program that exemplifies expert payer communications, education, and consistent follow up that resulted in the agreement of the payer to address the issue. Even though it was not possible to obtain a new code or modifier use for inadequate reimbursement, a solution was developed that required ongoing work with the payer, provider education and support.
GIRS researched the payer’s DME policy and fee schedule to verify the reimbursement by settings of care and modifier usage.
GIRS then met with the payer to discuss the new Product and its coverage, payment needs, and to verify the reimbursement rates. The payer confirmed that no prior authorization was required for the Product and that the code is covered. The payer agreed to review a payer dossier and all the requested information.
GIRS sent the payer dossier and the list price of the Product to the Executive Medicaid Director. After following up with the payer, GIRS received an acknowledgement of the payer dossier and responses to the coverage questions for the Product from the Deputy Secretary. The Deputy Secretary stated that the code was covered for all beneficiaries and that there is no age restriction for the code. Medicaid participating Medical Suppliers, Home Health Agencies and Pharmacies could bill for the code. GIRS was also informed that there would be no increase in reimbursement for the Product at this time for this code. If a prescriber cannot provide the service or the product for the Medicaid fee, the prescribers could request a Program Exception for the code. The prescribers must follow the procedure in the Provider Handbook for the Program Exception request. This was the suggestion of the payer to improve provider reimbursement for the Product code.
GIRS is working with the payer and the providers to ensure that all payer desired information is included in the Letter of Medical Necessity that is submitted for the Program Exception.
For more than 15 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 can also conduct a Reimbursement Landscape Assessment to develop payer-desired strategies with clinical outcomes experts, coding experts, policy staff, reimbursement lawyers, and a panel of current insurer medical directors. This work provides foundation reimbursement strategies that will influence and coordinate your company’s clinical outcomes, marketing, and reimbursement strategies to result in the best market access outcomes. The Payer Advocacy Compass® team can then implement these strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, please contact us by email
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