Our experts can help you navigate through the complex components of coding, coverage, and payment to help you gain reimbursement for your product. We help clients understand the payer’s perspective in determining reimbursement status by thorough assessment of the clinical and economic aspects of your product.
The US public and private health care system pays for health services and procedures via descriptive codes used to file claims services rendered.
Codes must be adequately descriptive of the service or procedure for legally compliant billing.
In the absence of a usable code, a new service, procedure. or technology must pursue a new code or use an unlisted code.
US public and private payers may cover services, procedures. or technologies deemed medically necessary. New technologies that meet medical necessary criteria may still face noncoverage if they are viewed as investigational/experimental.
Payers may limit market access and utilization by limiting coverage as follows:
By site of care (inpatient vs. outpatient)
To specific facilities (e.g., Centers of Excellence)
US public and private payment systems vary by site of care (e.g., inpatient, outpatient, physician office).
Payment for services, procedures, and technologies may be bundled (i.e., all costs, including technologies, are paid in a single predetermined payment) or can be eligible for payment as separate component procedures/procedural steps.
New technology utilization may be challenged by providers if use under bundled payment schedules diminishes the provider’s margin for rendering the procedure.
Obstacles in any one area can limit or preclude market access and ability to obtain sufficient payment.
