New and existing code analysis - The analysis will provide recommendations
as to any existing and new code reimbursement opportunities, how much
Medicare would pay if there is an appropriate code, a discussion with
Medicare to determine if there are anticipated changes in reimbursement
regulations that would impact the technology and an action plan designed to
obtain improved acceptance by commercial payors including how to increase
the wedge between your product and its competitors'
New code assignment - USTR can perform the many different types of activities required to prepare for and submit an application of a new code to the different code decision making bodies. If there is no code the product will be lumped into a miscellaneous category, causes insurance company auditing and case by case payment determinations.
USTR has extensive experience dealing with decision makers with respect to coding of medical devices. This has included successful negotiations with the Center for Medicare and Medicaid Services to obtain Medicare coding for products of USTR clients.
Coverage - A payor is going to do everything it can to say it is not paying for the service. It requires a cost justification best demonstrated with clinical studies. USTR will create a medical director executive summary and interact directly with insurance companies with a reimbursement presentation for the purpose of adding the device or service to the payors benefits plan.
New CPT code value generation - USTR can generate values for just received CPT3 codes and get the value benchmarked by a 3rd party coding organization. This is a very valuable service that provides credibility with providers. For a CPT1 code we can work with provider associations and survey physicians that would use the breakthrough device and develop the rvu and claim amount
Reimbursement seminar - USTR will conduct a lively and informative seminar related to reimbursement issues including behind the scenes of insurance company decision making and the micro and macro levels of decision making and how these issues impact claims for devices and services.
Reimbursement billing guidelines - Frequently asked questions of what you need to know when submitting claims for provider office use USTR will prepare a reimbursement guidance document for providers. This is a billing clerk procedure summary document with just the pertinent data for submitting claims. It includes codes to use, what medical necessity conditions must be met, can I bundle, what is the rvu, what documentation should be provided when submitting a claim to medicare and what generally causes a claim to be denied.
Reimbursement Training Program- A program for marketing managers and
dealers to explain reimbursement issues to their customers and utilize
reimbursement information to drive sales.
Accreditation of providers and devices - USTR will assist a provider association to create a program designed to obtain payor acceptance that the provider is the appropriate entry for the diagnosis and treatment for the medical condition the device is meant to treat. Also payor acceptance that the provider office is a cost effective alternative to other treatments and payor acceptance that qualified provider devices should be reimbursed.
New technology white paper - USTR prepares an analysis to answer questions related to the strategy to gain reimbursement. The reimbursement of existing codes from medicare, medicaid and independent insurance carriers and the market drivers and decision making processes in adopting new technology from those payors. For a product in premarket development we can determine what the pricing will be when the product hits the market and determine if higher coding values can be generated. This is a due diligence service to also evaluate the product for improved outcomes over competing products which will make the product more competitive in the marketplace. It provides an overview of coding and billing issues, develops an action plan for obtaining improved acceptance by payors and can provide a very educated ballpark value of what should be expected from reimbursement.
CPT Code Flowchart
