Our client contracted with us to support coverage and payment for their flagship biologic products. The GIRS Payer Advocacy Compass® (PAC) team began their work with a large, private payer in the state of North Carolina in August 2015. This payer has a majority share in the North Carolina payer market, and has both commercial plans and Medicare Advantage plans. During a policy review, GIRS found a medical policy that included positive coverage for one of our client’s products, but not the other.
The payer was contacted to review the details of the coverage information, and GIRS leveraged our previous working relationship with the Chief Operating Officer (COO) to identify payer needs for establishing positive coverage for the non-covered biologic. The GIRS PAC team then worked with the client to develop and send a dossier containing payer-desired information, thereby educating the payer on the value proposition of the product. The PAC team kept an ongoing dialogue with the payer and continued monitoring the coverage status for both biologics until June 2018, when GIRS was able to confirm with the payer that both biologics were now covered and appropriate payment was available for all settings of care.
The efforts of the GIRS PAC team ended up being a huge benefit for the client as they now not only have positive coverage for both products, but also have the most current information on how providers can submit clean claims for timely payment. This has assisted our client in developing strong sales force training and provider education, and they were strategically advised to update their sales force and their North Carolina accounts of the positive coverage and prior authorization requirements for this payer. Most importantly, all of this work improved patient access to breakthrough biologics that are supported by payer-desired outcomes.
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