WHG Specializes in Reimbursement and Market Access Consulting

Our innovative approach to health policy consulting is built on a two-step sequential process:
  1. A core set of essential strategy analytics 
  2. Focused reimbursement pathways ​
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 pathways are founded on 70+ years healthcare industry and government relations experience.

Health Policy Challenges that Affect 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. 
​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 a defined site of care and respective benefit category.
  • Clients frequently encounter denials because of site of care or benefit category issues.
​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​