WBBA INVEST NORTHWEST Reimbursement for New Medical Technologies

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WBBA INVEST NORTHWESTReimbursement for New
Medical Technologies
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Elements of Reimbursement
Coding
Coverage
Payment
Language describing services / procedures
Defines criteria for and extent of benefits
Adequate payment requires appropriate codes
and coverage


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New Technology Reimbursement

• The reality of novel device reimbursement
• Most new devices launched without dedicated
  codes, coverage, or payment
• Most new devices launched with little or no
  published data
• It takes time, data, and a significant effort to
  garner new codes, influence coverage policies/
  technology assessments, and drive appropriate
  payment

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New Technology Reimbursement

• Impact on sales due to lack of established
  reimbursement
• On the physician side, new technology is
  typically billed with unlisted (99) codes
• Unlisted codes carry more risk for physicians
• Unlisted codes are billed and reviewed manually
  and require additional clinical and economic
  information for the payer to make coverage and
  payment determination
• Manual claims submission slows payment process
  (60120 days for physician to be paid vs. the
  standard 30 days)

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New Technology Reimbursement

• Impact on sales due to lack of established
  reimbursement (cont.)
• On the facility side, new technology is typically
  incorporated into existing codes with established
  payment
• Economics of technology, as compared to
  alternatives, is the most important factor
  adding cost of technology requires saving costs
  in other ways, such as length of stay

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New Technology Reimbursement

• Can device manufacturers influence new technology
  reimbursement? Yes, by
• Developing an integrated reimbursement strategy
  EARLY in the product development process
• Incorporating as much of the strategy into
  clinical trials as possible
• Collecting data (clinical, utilization,
  costs/charges)
• Encouraging utilization
• Publishing data in peer-reviewed journals
• Encouraging provider advocacy
• Educating payers at every level

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Keys To Your Success

• Ensure that your business strategy is in synch
  with your reimbursement strategy
• Timelines for reimbursement success can be
  longer than the FDA process plan early
• Understand how reimbursement will enable or
  prevent product access / sales
• Understand the impact of your technology to
  patients, physicians, facilities, payers follow
  the money