The GIRS Payer Advocacy® (PAC) Team began working with a key regional payer in June 2015 to advocate for coverage for our client’s biologic products that were not covered by this payer. GIRS sent a payer dossier including our client’s most recent clinical studies and educated them about the value proposition of our client’s biologics. GIRS then monitored the payer’s medical policies until August 2018, when the payer updated their medical policies.
The PAC team analyzed the payer’s medial policies and found that the biologics were now covered based on specific criteria. The GIRS PAC team then called the payer. The payer stated that the procedure codes were covered with a medical review necessary on a case-by-case basis and that coverage was based on medical necessity. Additionally, the payer stated that providers would need to send the patient’s medical record and notes relevant to the case for the review. Further, the payer provided the medical review team’s contact information to send the patient’s medical records.
The coverage and payment in the various settings of care were also discussed and noted. This plan had numerous plans under it that were impacted by the coverage change. As the medical policy covers our client’s biologics and as the payer verified this and provided additional coverage details that would help accounts, we counted this as positive coverage based on medical policy for our client’s biologic products.
As a result of the PAC team’s work with the payer, all plans under them implemented positive coverage. This resulted in an increase in the potential market for our client’s product by approximately 40 million covered lives.
In addition to conducting payer research, policy analysis, and developing comprehensive payer advocacy strategies to enable positive coverage for our client’s product, the PAC team developed tools that educated our client’s sales force and key stakeholders of the new, positive coverage. Further, the PAC team made strategic recommendations to educate and support providers in ensuring appropriate billing for their Medicare Advantage 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.