The GIRS Payer Advocacy® (PAC) Team began working with a key regional payer in April 2018 to assist with the implementation of positive coverage for a medical device that the medical technology hotline reported as being denied during benefit verifications. The PAC team began their work by reviewing and analyzing the payer’s medical policies, identifying key areas for coverage discussions, and contacting the payer to advocate for coverage and appropriate payment.
The payer verified that the product and procedure codes were billable but required prior authorization (PA). The payer verified positive coverage and payment for all settings of care.
In addition, the PAC team established a direct line of contact between providers and the payer’s medical directors for policy specific questions as needed. Further, they were able to identify the correct process for claim reviews.
Finally, the PAC team educated the payer about the payer dossier, updating the payer on current clinical studies and value proposition of the product to ensure continued coverage.
As a result of the PAC team’s work with the payer, all 12 plans under them implemented positive coverage. This resulted in an increase in the potential market for our client’s product by approximately 3 million covered lives in the Southeast.
In addition to conducting a thorough policy analysis and enacting comprehensive payer advocacy strategies to enable positive coverage for our client’s product, GIRS developed tools that educated our client’s sales force and key stakeholders of the new, positive coverage. Moreover, GIRS made strategic recommendations to educate and support providers in ensuring appropriate billing for their patients.
If your accounts are experiencing claims denials for your medical device, drugs, biologics, or diagnostics, or if you need to improve the market uptake and patient access in key markets, our PAC team can assist you to meet your company goals.
To implement successful market access strategies, the GIRS Value Discovery Landscape Assessment® 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 will provide you with foundation reimbursement strategies that will influence and coordinate your clinical outcomes, marketing, and reimbursement strategies to result in the best market access outcomes. The PAC team can then implement these strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. Please contact us by email or call us at 1-844-514-4477 . Also, follow our LinkedIn Company Page for more bi-weekly news on reimbursement trends, milestones, and achievements.