Developing a Strategic Reimbursement Plan Second Annual Medical

Developing a Strategic Reimbursement Plan Second Annual Medical Device Regulatory, Reimbursement and Compliance Conference Jill Rathbun Galileo Consulting Group, Inc. March 29, 2007

Reimbursement: A “Three-Legged Stool” Coding Reimbursement Coverage Payment

Coding • CPT – 4 – Standard within healthcare industry – In 2000, CPT set as national standard under HIPAA of 1996 to report physician procedures and services • CPT codes must be used for electronic transactions • Inclusion in CPT does not necessarily mean insurance coverage – About 7500 CPT codes included in Medicare’s Physician Fee Schedule Ø Need Clinical Vignette of the steps in the procedures where the device is used

Coding • Categories of CPT Codes: – Category I Codes -Describe a service or procedure identified by a five –digit code and a descriptor – Category II Codes – Performance Measurement – Category III Codes – Emerging Technology

HCPCS Codes • The Federal Government develops and maintains HCPCS Level II Codes • Any supplier or manufacturer can submit a request for coding modifications • Deadline is once a year, January 3 rd or the first business day in January.

Payment • Questions to ask: – Sight of Service • • • Physician Office Hospital Outpatient Hospital Inpatient SNF Home – Supply or separately payable device • Included in procedure payment • Additional payment above procedure – Health Care Personnel Involved – Previous Pricing of other devices in same class – who is typical

Payment • Practice Expense RVUs • APC • Separately Payable – Cost or Cost plus • Capitation – DRG – Home Health Rates – SNF Rates – PT/OT Cap

Coverage • Medicare – General Medical Reasonableness – National Coverage Determination – Local Coverage Determination • Medicaid • Private Insurance • Coverage Limits

Things to Think About • Risk/Reward of Reimbursement • Investment of Resources and Time to Achieve End • Partners • Impact on Sales Strategy and Adoption

Working with Medical Societies • Identifying specialties that will use the device • Understanding who the leaders are in each society and the internal relationships and personalities • Where Societies Can Help You: – – CPT Code Applications Consensus Statements CAC Members Private Insurance

Questions? • Contact Information: • Jill Rathbun, Galileo Consulting Group, Inc. • 703 -486 -4200 • Jill_Rathbun@Galileogrp. com