The medical policy teams of insurers in the U.S. are busy in the first two quarters of the year conducting medical policy coverage reviews. Are you ready to educate the payers about your drugs, medical devices biologics, or diagnostics? If you are not tracking payer coverage, your accounts may be bringing non-coverage language or confusing coverage policy language to the attention of the sales representatives.
Below are five key steps to take to determine and address the root of the coverage issues:
- Work with an expert clinical outcomes team that is working closely with the payers to review the medical policy and identify the roots of payer coverage decisions;
- Conduct a gap analysis to determine if your clinical and cost data meet payer-desired criteria for study design, comparators, size of the study, and the number of studies.
- Develop a Value Proposition based on the current data;
- Work closely with experts who are knowledgeable about payer review processes and timelines;
- Track the feedback from the payers so that the clinical outcome strategies can meet the dynamic needs of diverse payers over a period of time.
Armed with this kind of information, it will be easier to assess the roots of the coverage issues, educate payers about your Products, and present your case to the payers.
See How We Help Our Clients with Their Clinical Outcome Strategies to Obtain Positive Coverage! Our Value Pointer Outcomes Strategies® team is almost always included in Landscape Assessments or Payer Advocacy projects to develop clinical outcomes strategies to support these projects. A notable project involved the reporting by a medical device manufacturer of non–coverage for an early detection diagnostic. It was reported as a coding issue. The medical policy and the 23 clinical and cost studies were reviewed to develop reimbursement strategies to meet the payer. The gaps in the studies were identified and presented to the client. The client decided to address the gaps in the studies to prepare for successful payer advocacy.
For additional expert guidance, please review our free E-book, Essential Steps for U.S. Payer Coverage: The Processes to Get Payer Reimbursement for Biologics, Drugs, Diagnostics, and Medical Devices.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
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About GIRS
For more than 19 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.