Traditional Fee -for-Service Medicaid was not covering and paying appropriately for our client’s Product.
Our client, a long-term Durable Medical Equipment (DME) client hired Global Integrated Reimbursement Services, Inc. (GIRS) to help overcome their two most critical challenges in a key market state:
- Lack of Fee-for-Service State Medicaid Program coverage for the Product
- Inadequate payment for the billing code
Understanding that lack of coverage and inadequate payment negatively impacts our client’s bottom line, GIRS developed a strategy to improve our client’s coverage outcomes.
The GIRS Payer Advocacy Compass® (PAC) Team researched the state Medicaid FFS program DME policy and fee schedule to develop payer advocacy strategies.
Payer Discussion and Negotiation
The PAC team then met with the payer to discuss the coverage, reimbursement, settings of care, prior authorization and modifier requirements, and the market for the client’s Product. The FFS Medicaid program was not covering the client’s Product but agreed to review the clinical and pricing data for the Product for future coverage.
The settings of care, the patient population that may be covered in 2021, and the product and billing guidelines and documentation were also identified with the payer.
Payer Education and Follow-up
GIRS consistently followed up with the payer and provided the payer with all necessary information that was requested by the Program Manager of the State Medicaid program to reverse the non-coverage and implement appropriate pricing.
The payer strategy and ongoing reimbursement efforts from the GIRS PAC team resulted in positive coverage from the FFS Medicaid program in this key market for our client.
To capitalize on the positive coverage outcomes with the FFS Medicaid program, GIRS decided to work with the Managed Medicaid plans in the same state to identify additional opportunities for positive coverage for the Product.
GIRS met with the two state Managed Medicaid plans in the same market regarding coverage for the client’s Product. GIRS presented the Product information, clinical data, and reimbursement needs to the two Medicaid Managed Care plans. GIRS’ payer negotiations, follow-up and overall market access strategies yielded the following results for our client:
Positive coverage and increased market access and uptake with a key payer in a key market
- Positive coverage from the FFS Medicaid program
- Positive coverage based on medical necessity from one Medicaid Managed Care plan.
Ongoing negotiation to address negative coverage and inadequate payment
- Agreement of the decision makers of the state Medicaid program to review and address the issue of inadequate payment for the client’s Product.
- Continued work with the Medicaid Managed Care plan that does not cover the Product in this market while the payer dossier is being reviewed by the plan. GIRS continued the payer advocacy work with the Managed Medicaid program that had negative coverage by sending the payer dossier, following up and negotiating the coverage and pricing. They agreed to review the data for 2021 coverage.
Reimbursement and Sales Force Support
- Verification of prior authorization (PA) requirements to assist providers with billing
- Development of a Sales Force education tool to educate the sales force about the coverage details and to sell safely to the providers.
This work has improved patient access with the Medicaid Managed Care plan and the FFS Medicaid program that have positive coverage in 2020 and allowed our client to plan their market access strategies for 2021 in this specific state that is a key market.
For payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements and to improve market uptake, visit us at girsinc.com . We are currently offering a free Reimbursement Needs Review to address Market access and uptake during the pandemic. Please also connect with us in LinkedIn and follow our company page.
About GIRS
For more than 17 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 and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.
