WHG Helps Clients Develop Health Policy Strategies to Navigate the New Era of Health Policy Focus and Political Ideology 

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  • New CMS reimbursement pathways in aggregate with the newly formed Technology Coding and Pricing Group to allow for faster access to innovative technologies.​​​
  • New CDC public health guidance, evolving as the knowledge base grows, and expanded/refined data reporting.​​
  • New NIH infectious disease research and expanded medical and behavioral health research.
WHG's innovative approach to health policy consulting and government relations is built on a two-step sequential process founded on 70+ years successful healthcare industry and government relations experience:
  1. A core set of essential strategy analytics - deep dive into the client’s requirements and an analysis of supporting data to develop executable solutions
  2. Focused reimbursement pathways - evidence based and data driven.
WHG provides 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's comprehensive reimbursement and market access pathways are founded on 70+ years healthcare industry and government relations experience.
​Establishing new IPPS/HCPCS/CPT codes does not equate to CMS coverage or adequate payment, these reimbursement steps are separate CMS processes.
FDA regulations and CMS reimbursement processes are not intuitive and can lead to uncertainties and market access complications

WHG Core Set of Essential Strategy Analytics

Comprehensive Medicare, Medicaid and commercial insurance reimbursement pathway analysis. 
Guidance through all 7-reimbursement steps - from diagnosis, treatment plan, site of care, and benefit category to coding, coverage and payment.
  • Clients can miss critical analytics at the beginning of the 7-step reimbursement process focusing first on coding, then coverage and payment.  
  • Coding, coverage and payment pathways first require site of care specific, defined benefit categories.
  • Clients frequently encounter denials because of site of care or benefit category issues.
7-Step Reimbursement Analytics
  1. Diagnosis - ICD-10-CM (Clinical Modification) Standardized system used to code and classify all diagnoses, symptoms, and procedures Enables standardized reporting for billing, research, and tracking healthcare. - ICD-10-PCS (Procedure Coding System) Seven-character alphanumeric code set used for reporting inpatient hospital procedures Drives provider specific DRG IPPS calculation payments.
  2. Treatment Plan - Physician "roadmap" for medical care that outlines treatments, goal(s) Directs the respective site of care for recommended treatments.
  3. Site of Care - Hospital, LTAC, SNF, IRF, hospital outpatient (HOPPS), homecare, ambulatory surgery center Each site of care has different and unique payment structures; fee-for-service, prospective payment, cost plus, bundled payment
  4. Benefit Category - Defined benefit category for each procedure, drug, treatment, product or service for the respective plan of care Benefit categories also vary by the site of care.
  5. Coding - Care setting and provider type specific unique code sets; DRG, APC, HCPCS Level I, HCPCS Level II HCPCS level I CPT codes maintained by the AMA, HCPCS Level II codes maintained by CMS 
  6. Coverage and Coverage Criteria - National Coverage Determination (NCD), or Local Coverage Determination (LCD); Policy/Billing Articles Coverage is based on peer reviewed published articles and guided by FDA approved or cleared indications for use.
  7. Payment - Each of the four legislated Medicare Insurance Plans, (Part A, B, C, & D) covers different healthcare-related costs Pays for these well-defined services utilizing 20 complicated fee-for-service and prospective payment systems.
​CMS utilization, mean costs and crosswalk data analytics are fundamental metrics of HHS and CMS decision-making trends. 
​CPT-RVU build up analysis - primary foundation of the annual Medicare Physicians Fee Schedule (MPFS) Rule Making process.
​WHG categorizes the foundation of the hurdles identified in the 7-step reimbursement analysis and CMS analytics - executable milestones.
  • Policy clarification
  • Benefit manual revision
  • Coding modification
  • Coverage expansion
  • Payment revaluation
WHG identifies the current political and policy landscape
  • Who can influence the change?
  • What is the appetite for change?​​
​​Strategy analytics is the foundation for developing reimbursement pathways

WHG 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
Are you Prepared for value-based payments?  In the absence of evidence lower cost pressures will always prevail​