Developing a Strategic Reimbursement Plan

1
Developing a Strategic Reimbursement Plan

• Second Annual Medical Device Regulatory,
  Reimbursement and Compliance Conference
• Jill Rathbun
• Galileo Consulting Group, Inc.
• March 29, 2007

2
Reimbursement A Three-Legged Stool
Coding
Reimbursement
Coverage
Payment
3
Coding

• CPT 4
• Standard within healthcare industry
• In 2000, CPT set as national standard under HIPAA
  of 1996 to report physician procedures and
  services
• CPT codes must be used for electronic
  transactions
• Inclusion in CPT does not necessarily mean
  insurance coverage
• About 7500 CPT codes included in Medicares
  Physician Fee Schedule
• Need Clinical Vignette of the steps in the
  procedures where the device is used

4
Coding

• Categories of CPT Codes
• Category I Codes -Describe a service or
  procedure identified by a five digit code and a
  descriptor
• Category II Codes Performance Measurement
• Category III Codes Emerging Technology

5
HCPCS Codes

• The Federal Government develops and maintains
  HCPCS Level II Codes
• Any supplier or manufacturer can submit a request
  for coding modifications
• Deadline is once a year, January 3rd or the first
  business day in January.

6
Payment

• Questions to ask
• Sight of Service
• Physician Office
• Hospital Outpatient
• Hospital Inpatient
• SNF
• Home
• Supply or separately payable device
• Included in procedure payment
• Additional payment above procedure
• Health Care Personnel Involved
• Previous Pricing of other devices in same class
  who is typical

7
Payment

• Practice Expense RVUs
• APC
• Separately Payable
• Cost or Cost plus
• Capitation
• DRG
• Home Health Rates
• SNF Rates
• PT/OT Cap

8
Coverage

• Medicare
• General Medical Reasonableness
• National Coverage Determination
• Local Coverage Determination
• Medicaid
• Private Insurance
• Coverage Limits

9
Things to Think About

• Risk/Reward of Reimbursement
• Investment of Resources and Time to Achieve End
• Partners
• Impact on Sales Strategy and Adoption

10
Working with Medical Societies

• Identifying specialties that will use the device
• Understanding who the leaders are in each society
  and the internal relationships and personalities
• Where Societies Can Help You
• CPT Code Applications
• Consensus Statements
• CAC Members
• Private Insurance

11
Questions?

• Contact Information
• Jill Rathbun, Galileo Consulting Group, Inc.
• 703-486-4200
• Jill_Rathbun_at_Galileogrp.com