WHG innovative approach to healthcare consulting based on core set of essential strategy analytics & focused reimbursement pathways

Health Policy = Strategy Analytics + Reimbursement Pathways

WHG’s innovative approach to health policy consulting is based on a core set of essential strategy analytics and focused reimbursement pathways based on real life healthcare industry experiences.
We provide clients a systematic and targeted engagement by working sequentially through interconnected groups of analytics to verify solid sustainable health policy strategies and reimbursement pathway tactics.
WHG specializes in healthcare consulting for pharmaceutical, medical device, specialty pharmacy, medical management, physician services, M&A advisors and innovators to help maximize stakeholder value.

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.

Core Set of Essential Strategy Analytics

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

Categorize the foundation of the hurdles or opportunities

Identify the current political and policy landscape

Strategy analytics is the foundation for developing reimbursement pathways

Focused Reimbursement Pathways

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

We determine the pathway tactics once the actionable reimbursement strategies are defined and prioritized

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?