The manufacturer of a breakthrough medical device who is a long-term GIRS client needed assistance obtaining favorable coverage and reimbursement for its flagship Product from a major U.S. payer. After several months of claims denials for the Product, the manufacturer reached out to GIRS to provide strategies for overcoming the non-coverage.
The GIRS’ Decryptase Coding Strategies® team and Value Discovery Landscape Assessments® team conducted a detailed Landscape Assessment with our Technical Expert Panel (TEP) of current insurer medical directors to develop appropriate clinical outcomes, payer advocacy, managed care contracting, and payment strategies for overcoming the hurdles.
Specific strategies were created by our Payer Advocacy Compass® Team to educate this large national payer. The payer policy was analyzed, and it was verified that the payer did not cover our client’s device or the codes. The indications that were covered for competitors for competitor products were also restricted. The list of references in the policy were also limited showing that the payer had not reviewed all the recently published scientific clinical and cost studies.
GIRS contacted the payer’s Medical Policy Operations Manager. The coverage for our client’s Product and its codes were discussed. The need to review the additional recently published clinical studies also were presented to the payer. The payer’s Medical Policy Operations Manager requested that GIRS sends the payer dossier to her. She would manage the evidence review with all the medical directors of the payer.
GIRS also had worked in the past with this payer to hold vendor presentations of new evidence. GIRS also requested that the client be allowed to present the clinical, cost, and product information to the medical directors. After following up for a few months, the vendor presentation date was obtained.
GIRS submitted the payer dossier to Medical Policy Operations Manager and guided the client on the important points that needed to be presented to the payer. As a result of the vendor presentation and the payer dossier submission, a Draft policy was posted with positive coverage for our client’s Product.
The providers and sales force were greatly encouraged that patients would have better access to this cost-effective therapy. However, GIRS needed to continue to support the Product with this payer because the Draft policy which was posted is not available anymore. This has caused the providers and the sales force to panic.
GIRS met with the payer and found out that policy needed more time to be finalized and uploaded. This greatly reduced the anxiety level of the providers and our client. It also shows that Payer Advocacy does not end with coverage. GIRS continues to work with payers to ensure that the coverage is implemented appropriately and that provider concerns are addressed.
For more than 16 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 or call us at 1-844-514-4477. Also, follow our LinkedIn Company Page for more weekly news on reimbursement trends, milestones, and achievements.