The GIRS Payer Advocacy® (PAC) team began working with a key payer in February 2018 for coverage and payment information after our client experienced persist claims denials for their medical device. 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 coverage and appropriate payment information.
The PAC team then initiated coverage discussions with the payer. Through their discussions, the payer verified that the product and procedure codes were not counted as investigational and applied to all settings of care dependent upon the member’s policy. In addition, the GIRS PAC team was able to obtain positive coverage for multiple plans under their policy, as well as identify the correct contact information and process for their claims reviews. Finally, the PAC team connected with the payer’s Medical Director to send them a payer dossier to educate the payer about current clinical studies and the value proposition of the product to ensure continued coverage for our client’s medical device.
As a result of the PAC team engaging in effective dialogues with the payer, the payer and six subsequent plans under their policy implemented positive coverage for our client’s medical device. This resulted in an increase in the potential market for our client’s product by approximately 3.7 million covered lives in the Mid-South.
Moreover, once our PAC team concluded their payer discussions and obtained positive coverage, they developed tools that educated our client’s sales force and key stakeholders of the new, positive coverage. Furthermore, GIRS made strategic recommendations to educate and support providers in ensuring appropriate billing for their patients.
If your accounts are experiencing claims denials for your medical device, drugs, biologics, or diagnostics, or if you need to improve the market uptake and patient access in key markets, our PAC team can assist you to meet your company 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 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 to improve market uptake. Please contact us by email or call us at 1-844-514-4477. Also, follow our LinkedIn Company Page for more bi-weekly news on reimbursement trends, milestones, and achievements.