Health Policy = Strategy Analytics + Reimbursement Pathways
Health Policy Challenges
- Government agency and reimbursement processes are not always intuitive and can lead to uncertainties and misconceptions.
- 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 potential downstream consequences. These FDA controlled regulations affect site of care utilization, benefit category determination, coverage criteria and payment.
- Establishing a new HCPCS/CPT code does not equate to CMS coverage or payment, as these reimbursement steps are separate CMS processes.
- The cost of innovation is not an inevitable part of payment calculation processes.
Comprehensive Medicare, Medicaid and commercial insurance reimbursement pathway analysis
- Guidance through all 7-reimbursement steps - from diagnosis, treatment pan, site of care, and benefit category to coding, coverage and payment. Too often, clients start in the middle with coding and not at the beginning of the pathway with the diagnosis.
- Encounter data analysis, metrics and trends - key drivers of HHS and CMS decision-making trends
- CPT-RVU build up analysis - key drivers of the annual Medicare physicians fee schedule (MPFS) rule making process and trends
- Identify hurdles and opportunities in the six step reimbursement pathway
- Policy clarification
- Benefit manual revision
- Coding modification
- Coverage expansion
- Payment revaluation
- Who can influence the change?
- What is the appetite for change?
We identify the foundation of reimbursement hurdles or opportunities and prioritize executable milestones to maximize reimbursement
- Policy Clarification – Less formal instrument to expanded coverage criteria
- Benefit Manual Revision – Subject to legislative language interpretation and clarification
- Coding Modification – New code, descriptor modification, code verification
- Coverage Expansion – More formal evidence based route to expanded coverage criteria in the form of an NCD, LCD and policy article
- Payment Revaluation – Update pre-set data points, multi-layered variables and complicated formulas utilized to calculate fee schedules and prospective payment rates
- Determine HHS and CMS policy jurisdiction
- Outline HHS and CMS decision-making processes
- Identify HHS and CMS key decision-makers and influencers
- Determine Capitol Hill policy jurisdiction, appropriations and oversight responsibilities
- Identify Capitol Hill key decision-makers and influencer
Health Policy Trends - Are You Prepared?
- Expanded Medicaid
- Legislated Alternative Payment Models (APMs)
- Bundled payments
- Consolidating health systems
- Consolidating payers
- Local Coverage Determinations (LCD) revisions
- National Coverage Determinations (NCD) revisions
- Price erosion
- Quality measures and standards
- Value-based pricing
- Tighter coverage criteria
- Prior authorization