Coverage and Payment Services/
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The assignment or confirmation of the appropriate CPT or HCPCS code does not imply that the technology or service will be covered or reimbursed. Third-party payers finance and manage most medical care in the United States. Payer coverage policies have a major impact on product utilization and payment which directly influences dissemination and market uptake.
In the post launch phase, payer advocacy swings into high gear and our payer alliance experts work closely with payers to help inform them of the benefits of our clients' products. We help the manufacturer to keep proving the case for the requisite technology by providing payer desired data to implement and maintain coverage and payment.
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Core payer alliance and reimbursement services include: |
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Why Hire GIRS for Payer Advocacy Services?
Knowledge- GIRS knows the major decision makers, review processes, and preferred communication methods for the top 50 National Commercial Payers, top private payers in each state, Medicare, Medicaid, and Workers’ Compensation.
- GIRS is knowledgeable about the specific payer coverage requirements and policies for a wide range of pharmaceuticals, biologics, medical devices, diagnostics, surgical supplies, and combination products.
Experience
The GIRS team:
- Interacts with approximately 20 payers and their policy staff per day to present dossiers of client products.
- Has over 25 years of experience communicating directly and openly with payers about client products and their clinical outcomes-this has led to the establishment of relationships based on trust and competence.
- Has over 25 years of experience communicating openly and honestly about payer data and coverage next steps with our clients-this has helped our clients to develop realistic executive plans that have successful outcomes and to proactively develop solutions for obstacles in the future.
- Has successfully developed dossiers based on payer review needs and preferences for data and study design-this has facilitated convenient reviews of the payer packages.
- Has developed several clinical and health economic tools to help educate payers about the clinical and cost outcomes of client products.
- Has over 25 years of experience developing professional society support by working with key decision makers and their committees to support coverage initiatives.
- Has developed customized reporting tools for executives to track coverage trends and their impact on sales.
- Has worked with external review organizations to facilitate reviews of client technologies to implement positive coverage by payers who reference these studies
- Has several years of experience educating payers on appropriate payment for client medical technologies.
- With the help of reimbursement lawyers, we help clients understand ASP regulations and the calculation of ASP.
- Has several years of experience submitting comments on Local Coverage Determinations (LCDs) and evidence reports that influence coverage for client products.
Proven Outcomes/Case Examples of Success
- Obtained positive coverage for a biologic product as a result of professional society support developed by GIRS. When the payer requested the specialty society for input from the membership on the use of the specific biologic and its outcomes, the feedback provided by the specialty society to the payer led to the establishment of a positive coverage policy for the biologic product.
- Eliminated competitor advantage for a drug due to incorrect implementation of coverage policy by educating the payer of the inconsistencies in the coverage policy implementation.
- Positive coverage by many payers due to the publication of a randomized control trial (RCT) of a biologic product-the payer desired endpoints were provided to the clinical study team by GIRS.
- Reversal of several Medicare and commercial payer non-coverage policies for an extracellular matrix (ECM) within one year, as a result of payer alliance work.
- GIRS was the first to educate Medicare contractors about Tissue products-this led to positive Medicare coverage by some Medicare contractors within six months of product launch.
- Appropriate pricing for a surgical supply, due to pricing and reimbursement information provided by GIRS to the payer.