Payer Advocacy Services

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About Payer Advocacy Compass™ Services

Payer coverage and payment require more than assigning or confirming the appropriate CPT® or HCPCS code. Third-party payers finance and manage most medical care in the United States. Payer coverage policies have a major impact on product utilization and payment which directly influences patient access and market uptake.

In the post launch phase, payer advocacy swings into high gear and our Payer Advocacy Compass™ (PAC) team works closely with payers to help inform them of payer desired outcomes/data and the value story for our clients’ Products. We help the manufacturer to present safety and efficacy data, outcomes from randomized controlled trials (RCTs), Patient-Reported Outcomes (PRO) and Real-World Evidence (RWE) to keep proving the clinical effectiveness and the value proposition for the requisite technology to implement and maintain coverage and payment.

Need Assistance? Let our reimbursement specialists evaluate your needs.

Services

Core payer alliance and reimbursement services

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  • Conduct Payer Mix Analysis.
  • Develop effective Payer strategies for our clients’ medical technologies with input from GIRS Payer Panels and other key stakeholders.
  • Monitor and identify future and current changes in payer policies, fee schedules, and payer regulations, for Medicare, commercial payers, Medicaid, and Workers’ Compensation.
  • Educate and work with commercial payers, Medicare contractors, Workers’ Compensation plans, Medicaid, ACO plans, Medicare Advantage plans, Medicare Part D, and self-insured groups to obtain coverage and appropriate payment for our clients’ medical technologies.
  • Working with external review organizations to initiate, identify and comment on changes real time.
  • Model coverage policy development for client Products
  • Model Health Technology Assessments (HTAs), pricing sensitivity analysis, dossier development and payer mailings
  • Average Sales Price (ASP) submissions support for pharmaceuticals and biologics development of payer advocacy trend reports for executive reporting
  • Innovative contracting facilitation including risk based contracts
  • Development and submission of comments for coverage policies; Centers for Medicare and Medicaid Services (CMS) Proposed Rules and other areas that provide commenting opportunities for our clients, The Agency for Healthcare Research and Quality (AHRQ) reports.

Benefits of our Services for

Benefits for Your Accounts

  • Appropriate reimbursement for breakthrough medical technologies Leads to Product Adoption and Patient Access
  • Reduced account frustration due to the clarification of confusing language in policies leading to accurate billing, coding, and payment for your Products
  • Specification of payer coverage guidelines, documentation and utilization guidelines, and payment restrictions lead to timely and clean claims submissions

Benefits to Medical Technology Manufacturers and Marketing Companies

  • Competitive education of the sales force and company executives on payer and review organization changes and reports to enable on-time commenting, education of payers, and strategies.
  • The GIRS PAC team assists companies to develop payer – focused clinical outcomes strategies that include payer – desired variables, PRO, and RWE. This helps to reduce the costs of conducting studies that do not meet payer coverage needs.
  • The implementation of positive coverage expands the payer markets where the new coverage is implemented for our clients’ pharmaceuticals, medical devices, biologics, and diagnostics; this improves patient access to and market uptake of new medical technologies.
  • Our clients refer account coverage and payment complaints and issues to the capable hands of our GIRS PAC Team.  The effective handling of these issues help our clients to maintain their client base.

Benefits to Payers

By acting as an effective bridge between the payer and manufacturer, the GIRS PAC team is able to meet both the payer needs for data and the manufacturers’ needs for coverage and payment.

We have the industry relationships necessary to be effective advocates for you in your quest for coverage.

Why Partner with GIRS for Payer Advocacy Services?

Knowledge

  • GIRS works with the major decision makers and we are familiar with the review processes, and preferred communication methods for the top National Commercial Payers, top private payers in each state, Medicare, Medicaid, Workers’ Compensation, Medicare Advantage, Medicare Part D, Medicaid Managed Care, and Federal Marketplace plans.
  • GIRS is knowledgeable about the specific payer coverage requirements and policies for a wide range of pharmaceuticals, biologics, medical devices, diagnostics, surgical supplies, and combination products.

Years of Experience:

  • Assisting clients to develop payer desired clinical studies
  • Partnering with payers and clients to design and implement Coverage with Evidence Development initiatives
  • Communicating directly and openly with payers and clients about Products and their clinical outcomes
  • Developing clinical and health economic tools to help educate payers about client Products
  • Developing dossiers based on payer needs
  • Developing professional society support
  • Helping to facilitate payer reviews of client technologies
  • Partnering with payers and clients to implement risk based contracts
  • Educating payers on appropriate payment for client medical technologies.
  • Helping clients to understand and submit ASP data
  • Submitting comments on Local Coverage Determinations (LCDs) and evidence reports

Proven Outcomes

  • Obtained positive coverage by many payers as a result of professional society support developed by GIRS and publications of randomized control trials (RCTs).
  • Eliminated competitor advantage for a drug due to incorrect implementation of coverage policy by educating the payer of the inconsistencies in the coverage policy implementation.
  • Reversal of several payer non-coverage policies for an extracellular matrix (ECM) within one year, as a result of payer alliance work.
  • First to educate Medicare contractors about Tissue products, leading to positive Medicare coverage by some Medicare contractors within six months of product launch.
  • Appropriate pricing for a surgical supply, due to pricing and reimbursement information provided by GIRS to the payer.

Need Assistance? Let our reimbursement specialists evaluate your needs.

Payer Advocacy Testimonials

GIRS Payer Advocacy Compass™ support lead to increased market access for our flagship product, improved patient access, provider satisfaction and reduction of confusion, and eventually we were acquired by a large company.

Due to the excellent and thorough Landscape Assessment that lead to Payer Advocacy and clinical outcomes strategies, our company was able to obtain Medicare coverage for a biologic in one year after experiencing non – coverage for eight years.  Our company was acquired by a large company due to the reimbursement support we received from GIRS for our flagship product. We are continuing to work with the GIRS Payer Advocacy team in other payer markets and for additional products.

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Corporate Office
65 Germantown Court, Suite 404
Memphis, TN 38018
(P) 1-844-514-4477
(F) 1-901-752-0238

Maryland Office
6701 Democracy Blvd., Suite 300
Bethesda, Maryland, 20817

info@girsinc.com

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