The GIRS Payer Advocacy® (PAC) team began working with a key payer in 2013 on coverage and payment after our client reported experiencing varying coverage outcomes for their two biologic technologies. The PAC team began their work by researching the payer, reviewing and analyzing the payer’s medical policies, identifying key areas for coverage discussions, and coordinating strategies for obtaining positive coverage and appropriate payment.
The team then initiated these coverage discussions with the payer, who verified that the product codes were not included in the medical policy. The codes could, however, be approved on an individual basis, after a case review was conducted by the payer’s clinical review team.
In August 2015, the payer’s policy was updated to include positive coverage for one of the two product codes. The other remained a non-covered product, as it was deemed experimental and/or investigational by the payer, so a payer dossier was sent in order to educate the payer about the clinical, regulatory, and economic information for the technology.
After meeting with the payer and submitting additional clinical studies to be included in their review of the payer dossier, the GIRS PAC team was able to not only maintain ongoing coverage for the first product, but also obtain new, positive coverage for the second. As a result, 36 local payers and each of their subsidiary plans implemented positive coverage for the biologics. This resulted in an increase in the potential market for our client’s products by approximately 8 million covered lives in United States and its territories.
To maximize this win for our client, GIRS made strategic recommendations to educate and support providers in ensuring appropriate billing for their patients. Additionally, the PAC team developed tools that educated our client’s sales force and key stakeholders of the new, positive coverage.
If your accounts are experiencing claims denials for your medical devices, drugs, biologics, or diagnostics, or if you need to improve market uptake and patient access in key markets, our PAC team can assist you to meet your strategic 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 the help of clinical outcomes experts, coding experts, policy staff, reimbursement lawyers, and a payer panel of current medical directors. This work will provide you with foundation reimbursement strategies that can influence your clinical outcomes, marketing, and reimbursement strategies, and help you to achieve 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 for your product.
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