Comprehensive reimbursement strategy aimed at key decision makers results in favorable coverage for ophthalmic diagnostic device with large Medicare carriers.
Business Challenge
A manufacturer of a new visual field device used to evaluate the early onset of wet age-related macular generation (AMD) experienced problems with coverage for their technology. During early communications with Medicare carriers, some determined that procedures performed with the AMD diagnostic should be packaged into the coverage and payment for general eye exams, similar to many other basic ophthalmic diagnostics services. However, the client, clinical study investigators, and early adopters of the technology contended that the physician work and resource utilization associated with the device are more indicative of visual examinations. Consequently should be covered and paid separately like other visual field devices.
Our Approach
Quorum worked with the client to develop a comprehensive post-launch reimbursement strategy to educate Medicare local coverage determination (LCD) decision-makers about the new AMD diagnostic tool via local physician advocates.
Our Solution
Quorum’s experience in working with physician specialty groups and local Medicare carrier medical directors allowed us to develop a comprehensive plan. The plan included identifying local Medicare LCD decision-makers (i.e. Medicare medical directors and ophthalmology carrier advisory committee members); assembling a clinical and reimbursement focused briefing binder to educate payers and establish favorable Medicare coverage; developing collateral materials to solicit and train early adopters on the reimbursement action plan; educating and training the sales force on the action plan and coordinating with physician advocates and local Medicare LCD decision-makers to communicate clinical and reimbursement messages associated with the AMD diagnostic device.
Results Delivered
Within ten months of initiating the comprehensive reimbursement strategy, Quorum helped to overturn successfully initial unfavorable reimbursement decisions about the AMD diagnostic. Two of the largest Medicare Carriers (covering 16 states) were receptive to reimbursement materials and messages, and issued formal decisions outlining favorable coverage for the AMD diagnostic device within the existing visual field examination policies allowing for separate payment outside of the general eye exams.
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