Situation

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.

The clinical studies not only supported the improvement of quality of life in patients but it indicated significant long term cost savings for the health care system. A few months before expected FDA approval, there was no reimbursement strategy for the product or the peptide imaging procedure. The only codes available to hospitals were general imaging codes. Although this product was a breakthrough in medical technology, most hospitals were concerned that the lack of appropriate reimbursement would not cover the cost of the study. All claims filed under general codes would require paper claims with a copy of the imaging report attached. This process was not only time consuming and costly but appropriate reimbursement to the hospital was not guaranteed.

Solution

The Pinnacle Health Group designed and successfully implemented a reimbursement strategy which provided appropriate levels of reimbursement within nine months. As an interim solution, coding options were outlined for hospitals. Our staff also worked with individual hospitals and the local payers to assure that this new technology was reimbursed. In a concurrent effort, appropriate coding applications were submitted and a HCPCS code (for the peptide imaging agent) along with a CPT code (for peptide imaging for DVT) were both granted in less than nine months.

Outcome

After careful research and evaluation of the issues at hand, The Pinnacle Health Group designed a reimbursement strategy that fit our client’s goals and objectives. We achieved appropriate levels of reimbursement and appropriate coding for the peptide agent and the study procedure. This permitted hospitals to initiate use of the key diagnostic study, showing reduced costs to the health care System by identifying better those patients at risk for stroke at an early stage. Additionally the efforts by The Pinnacle Health Group helped the company achieve their expected market objectives.