Success Cases

Success Cases

Hotline Success Cases

Achieving far reaching changes…

The GIRS InContact Reimbursement Line™ for a biologic received account pushback on the codes verified by the AMA because of coding advice that was being published in industry journals that conflicted with the AMA verified codes.

The President of GIRS personally worked with the AMA to verify the coding again and the GIRS InContact Reimbursement Line™ educated the accounts about product coding.

The work with the AMA resulted in the assignment of a specific code to the technology, thereby reducing confusion. This is a perfect example of how the GIRS InContact Reimbursement Line™ can not only recognize serious issues that are reported on the hotlines, but also develop coding strategies/solutions to resolve these issues with key stakeholders and decision makers.

Clean claims and expansion of use

The GIRS InContact Reimbursement Line™ met with a physician who indicated that he was using an injection during surgeries but was not aware it could be used in an office outpatient setting. The physician asked how he could obtain the materials/supplies to conduct in-office injections and also informed the counselor that he was considering billing a code for the biologic. The physician also informed the counselor that he had a patient he would love to use the injection on within the next few weeks.

The reimbursement counselor educated the provider of the correct code to bill for the injection based on the Billing Guide. The counselor also informed the provider that the HCPCS code they were considering was not appropriate for the biologic. The counselor also provided the physician with the product brochure, the Billing Guide, a sample Letter of Medical Necessity (LMN) and a patient authorization consent form for benefit verification purposes. In addition, the counselor also reported the case to the client to request that a sales rep visit the facility to provide them with the materials/supplies. The physician was so impressed with the information provided by the counselor that he asked if the same information could be sent to his daughter’s practice. The counselor forwarded all information to the referred practice. Due to the education provided by the GIRS Hotline, the physician obtained the information necessary to submit a clean claim and the use of the client technology expanded to the physician office setting.

Success in Appeals Assistance

The GIRS InContact Reimbursement Line™ received a request for appeals assistance. The provider indicated that she did not get paid for the use of the device. The counselor offered to contact the payer to ascertain what can be done to appeal the denial. The provider gladly accepted the counselor’s offer. The counselor contacted the payer and gathered all the necessary information

for the appeal. After contacting the payer, the counselor found that the provider could not prescribe the device and needed their patient’s Primary Care Physician to prescribe the device. The GIRS InContact Reimbursement Line™ was able to decipher the complex claims submission rules in order to help the account helped them to submit their appeal and get paid for the device.

View more Reimbursement Hotline Success Cases on our Blog.

Coding Application Success Cases

Case examples of successful Coding Applications:

  1. Developed a successful coding strategy for the sheet and injectible versions of a tissue product. With KOL support, educated CMS regarding the regulatory and reimbursement requirements for the same. This was the first tissue product ever reviewed by CMS. Information was provided to a team of CMS physicians and policy staff of the unique FDA regulatory process for tissue products and provided input to modify FDA requirement for HCPCS codes. Successfully obtained a “J” code, a C code for pass through payment in the hospital outpatient department, and a “J” code for the injectible version of the product.
  2. Identified appropriate CPT codes and submitted coding verifications to several diagnostic tests, therapies for malignant melanoma, acute mylogenous leukemia, and hepatitis C, and organ transplant anti-rejection drugs.
  3. Provided input into the revision of vascular access codes, skin substitute codes and pathology laboratory tests sections of CPT Coding Book by working with the professional societies responsible for managing the revisions.
  4. Obtained a unique “J” code for a recombinant monoclonal antibody.
  5. Obtained a collagen wound filler coding category and successfully avoided the classification of the client product in the unclassified wound filler category by providing appropriate and compelling rationale.

Payer Advocacy Compass™ Success Cases

Case examples of Payer Advocacy Compass™ successes:

  1. Successfully obtained coverage and appropriate payment for totally subcutaneous vascular access device from Medicare, Medicaid, and some private payers although competitor product catheters were less costly than client device. This was accomplished over a period of 2-3 years by providing clinical and cost data to show better outcomes and cost savings to the payer.
  2. Positive Medicare coverage for a tissue product within six months of product launch. Convened a payer panel meeting to review a model health technology assessment tool, to develop model coverage policy, and to identify payer desired outcomes for clinical studies to support the private payer strategy of a tissue product.
  3. Reversal of several non coverage policies for a zenograft within one year based on Payer Advocacy Compass™ work. Development of private payer strategies for the same product including the analysis of payer coverage policies and the development of strategies to target the reasons for non – coverage.

Value Pointer Outcomes Strategies™ Success Cases

Outcomes Strategies to Address a Medicare National Non Coverage Decision (NCD)

The GIRS Value Pointer Outcomes Strategies™ team reviewed the study design and available clinical studies for a biologic and developed clinical outcomes and payer coverage strategies to address the Medicare National Coverage Determination (NCD). The payer coverage and reimbursement strategies to address the NCD were one of the factors in the company being acquired by one of the largest manufacturers in this area of therapy.

Outcomes strategies to address Medicare and Commercial Payer non coverage of two devices

The GIRS Value Pointer Outcomes Strategies™ team reviewed the study design and available clinical studies for two medical devices and developed clinical outcomes strategies to address the Medicare, Medicaid, and commercial payer non coverage.  The team implemented the payer advocacy strategies successfully.  Within one year, most of the Medicare contractors covered the devices.  Commercial payers and Medicaid continue to expand coverage.  Patient access and account loyalty increased as the payer coverage expanded.  The company was acquired by one of the largest device manufacturer in the world who is our client now.  We are expanding our reimbursement consulting work with the new company reviewing the data for other Products and developing successful outcomes strategies to overcome payer coverage and payment issues.

The GIRS Value Pointer Outcomes Strategies™ team worked with a client and high user provider who had collected data to develop a Health Economic Model to educate Workers’ Compensation payers about better return to work, reduced pain medications, and better functioning outcomes with the use of the client’s biologic.  This helped to expand coverage in the Workers’ Compensation market.

The GIRS Value Pointer Outcomes Strategies™ team reviewed the clinical evidence for a drug that replaces iron losses without increasing ferritin levels and iron stores from a payer desired evidence perspective.  An Evidence Table, dossier and Value Proposition were developed to show that the drug is a superior therapy for replacement of iron in chronic kidney disease patients on hemodialysis that does not share the negative aspects of intravenous and oral iron therapy, such as cumbersome administration and iron sequestration in the reticuloendothelial system, and poor gastrointestinal absorption and patient compliance.  It was also emphasized that the drug has also been shown to substantially reduce ESA use in chronic kidney disease patients on hemodialysis, representing a large cost savings while replacing iron and maintaining hemoglobin. The coverage tools that the Value Pointer Outcomes Strategies team developed helped with Product adoption and patient access.

International Reimbursement Beacon™ Case Examples

GIRS conducted several Landscape Assessments for a biologic in the E.U. and Canada that was being successfully supported in the U.S. The resulting strategies for France, U.K., Belgium, Germany, Spain, Italy and Canada allowed the client to manage its global reimbursement work under one company.  This allowed for cohesive and more cost effective budgets for the work and better outcomes that were coordinated.

GIRS conducted several Landscape Assessments for a point-of-care diagnostic in the E.U. and Canada. This work allowed the client to determine launching strategies in each country based on payer requirements in each country.

GIRS conducted a pricing and market access analysis for a drug in Canada that allowed our client to obtain positive outcomes and market uptake after Product Launch.


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