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Appropiate Device Reimbursement

The client contacted The Pinnacle Health Group thirteen months following FDA approval. The company had been without reimbursement for costly technology for over a year and the ability to market the technology was difficult. The company requested assistance achieving appropriate reimbursement and procedure/device codes for future payment. The company also faced other payer related issues including; a negative Blue Cross Technology Assessment, limited positive payer policies and difficult physician reimbursement.

Strategic Product Positioning

In 1997, a company first introduced imaging enhancement peptides to detect blood clots in lower extremities for the prevention of strokes. Studies demonstrated that their newly developed imaging agent would significantly improve the quality of life and reduce the cost of care within the health care system. However, the company lacked a tailored reimbursement strategy and quickly recognized that their product would not be evaluated at its full potential among competitive products. The company was concerned that sales would fall short of market projections desired objectives.

Product Cost Justification

The CMS Hospital Outpatient Prospective Payment System (HOPPS) proposed regulations were released which recommended a decrease in reimbursement based upon claims data analysis in reimbursement for the High Dose Rate (HDR) brachytherapy APC. However, the basis for decreasing reimbursement was based on unreliable claims data resulting from the numerous changes in coding implemented under the HOPPS program. The reduction in the APC value threatened to limit the number of facilities that could offer HDR brachytherapy to patients due to the significant loss in revenue imposed by the proposed new reimbursement rate. The client contacted The Pinnacle Health Group to request support to provide CMS with appropriate data to update the cost of HDR brachytherapy.

Reimbursement and Collections

Well known and respected physician provider group contacted The Pinnacle for support and solutions relating to aged accounts receivable collection. The physician provider group had terminated their prior collections company and was experiencing problems with their aged accounts receivable data, collection of the aged accounts receivables and claims resubmissions.

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