In August 2018, the GIRS Payer Advocacy Compass® (PAC) team began working with an important payer in the Midwest to assist with the implementation of positive coverage for a medical device that was experiencing negative coverage and payment. The PAC team conducted extensive research, and identified a medical coverage policy that had positive coverage for our client’s product. We analyzed the policy for the relevant coding, coverage, and other information that would impact our client’s device. The team then met with the payer to verify all of the coverage, coding, billing, documentation guidelines, and other details in order to educate our client’s sales force and provider accounts.
As a result of the PAC team’s work, GIRS was able to report positive coverage for this payer’s commercial, marketplace, Medicare Advantage and Medicaid managed care plans. Specifically, the verification of this positive coverage with the payer showed that it applied to all HMO plans, all PPO plans, all individual marketplace plans, all Medicare plans, and all Medicaid plans that are under this payer. Also, as a result, an additional 344, 000 covered lives in the payer’s market now have access to positive coverage.
In addition to conducting payer research and policy analysis, and developing comprehensive payer advocacy strategies to maintain positive coverage for our client’s product, we also developed tools that educated our client’s sales force and key stakeholders of the positive coverage for our client’s device by this payer and all the plans under it.
GIRS provided strategic guidance to our client to educate the sales force, providers and other stakeholders of the coverage details. In addition, GIRS sent a payer dossier to educate the payer about new clinical and cost studies to maintain the ongoing coverage. As coverage is dynamic, the GIRS PAC team will track the payer coverage as appropriate.
If your accounts are experiencing negative coverage or inadequate payment for your medical device, drugs, biologics, or diagnostics, or if you need to improve market uptake and patient access in key markets, the GIRS PAC team can assist you to meet your company goals.
GIRS has been providing reimbursement expertise to drug and medical device manufacturers for more than 15 years. Our PAC team includes experts who will work directly with public and private payers at the national, state, and regional level to inform them of the data and the value that your product presents for their clients. To prove clinical effectiveness, we assist our clients to present safety, efficacy, and outcomes data in order to gain, and maintain, ongoing coverage and reimbursement.
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 for improving market uptake. For more information, please email us or call us at 1-844-514-4477. Also, follow our LinkedIn Company Page for more weekly news on reimbursement trends, milestones, and achievements.