About Us - We Come From Industry
Our innovative approach to health policy consulting is built on a two-step sequential process:
- A core set of essential strategy analytics
- Focused reimbursement pathways
WHG's comprehensive analytics and reimbursement pathways are founded on 70+ years healthcare industry and government relations experience.
Our mission is to help clients maximize stakeholder value
Why Our Industry Experience Matters
The U.S. healthcare delivery system, unlike any other industry and unlike any other country's healthcare system is:
Health policy decision-making and reimbursement methodologies are largely driven by federal government initiatives and generally adopted by commercial payers.
WHG understands the nuances of the complex U.S. healthcare delivery system and provides strategy analytics and reimbursement pathways based on real-life healthcare industry and government relations experiences.
Are you prepared for the ever-changing health policy ideology?
WHG Process Begins in Washington D.C.
Achieving success in healthcare requires an in-depth understanding of the influence political ideology and government policy have on reimbursement processes and agency regulations.
The U.S. Government is the largest funder and primary driver of health policy:
- Ideology = Administration and Congress
- Policy Legislation and Appropriations = Congress
- Interpretation and Implementation = Federal Agencies
Reimbursement methodologies are convoluted and involve multiple agencies with overlapping jurisdiction. The biggest and most powerful funder, HHS, has eleven agencies, 2018 outlays = $1.13 Trillion.
WHG understands the processes and knows the responsible decision-makers.
We Come From Industry - As a Result, WHG is uniquely positioned to best understand our client’s challenges and develop targeted government relations’ strategies.
Health Policy Challenges That Effect Reimbursement and Market Access
FDA approval and FDA clearance allows for commercialization. It does not mean that a product is covered or eligible for reimbursement by Medicare, Medicaid, or commercial insurance.
FDA approved indications for use and FDA product coding can result in downstream consequences with significant reimbursement pathway implications.
FDA controlled regulations affect CMS controlled policies determining site of care utilization, benefit category, coverage criteria and payment mechanisms.
FDA regulations and CMS reimbursement processes are not intuitive and can lead to uncertainties and market access complications
Case in Point Examples:
- New drugs covered under Part B vs. Part D have significantly different payment calculation systems.
- New HCPCS J-Code or C-Code pass-through status or both?
- New or modified IPPS/HCPCS/CPT code pathways?
- New or updated CPT code through the AMA-CPT/RUC Process vs. the CMS Medicare Physicians Fee Schedule Rule-Making Process?
- New drugs & new technologies covered under Part A MS-DRG vs. New Technology Add-On Payment (NTAP)?
Establishing new IPPS/HCPCS/CPT codes does not equate to CMS coverage or adequate payment, these reimbursement steps are separate CMS processes.
The Cost of innovation is not an inevitable part of the CMS payment calculation processes
Wells Health Group Consulting Services
Health Policy Consulting - WHG's innovative approach is built on a two-step sequential process.
Strategy Analytics - Comprehensive Medicare, Medicaid and commercial insurance reimbursement pathway analysis.
Reimbursement Pathways – We identify the foundation of reimbursement hurdles and opportunities.
DC Based Government Relations - WHG understands the nuances of how the Administration, Congress and Federal Agencies shape healthcare policy.
The WHG team’s years of healthcare industry and government relations experience positions us uniquely to best understand our client’s challenges and develop targeted government relations strategies.
Health Policy Legislation - In Congress at least 6 different full committees and their respective subcommittees have appropriations, jurisdiction and oversight responsibility over healthcare.
Health Policy Implementation - HHS - CMS - FDA have multiple centers, offices and administrative contractors with regulatory oversight and often-overlapping jurisdiction over healthcare reimbursement coding, coverage and payment methodologies.
Evaluating Reimbursement and Market Access Policies - One of the most critical and challenging analytics of healthcare M&A due diligence
WHG can help clients prepare for a successful due diligence process.
How well is the client positioned for funding or coverage challenges and the inevitable shift from fee-for-service to value-based payments?
WHG understands the health policy challenges and misconceptions that can affect transactions.
WHG help's clients evaluate a transaction’s potential to maximize stakeholder value based on real-life experiences.