Major Accomplishments

The following are examples of only a few of Reimbursement Principles' significant accomplishments.

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Significant Accomplishments

  • Successfully petitioned the ICD-9-CM Coordination and Maintenance Committee to develop new hospital inpatient procedure code for coronary atherectomy procedure, enabling hospitals, payers and health care statisticians to track cost and utilization of coronary atherectomy separate from coronary angioplasty.
  • RPI secures new ICD-9-CM diagnosis code for severely calcified coronary lesion(s)
  • RPI successfully appeals DME item through the Administrative Law Judge (ALJ) process. Claims for this Durable Medical Equipment item were repeatedly denied by Medicare contractors who believed the equipment to be a personal convenience item, not covered under the Medicare program.
  • Coordinated meeting between CMS Deputy Director, Hospital and Ambulatory Policy, Centers for Medicare Management and manufacturer of implantable middle ear prosthesis to clarify benefits and avoid misunderstandings with benefit category determination for prosthetics versus hearing aids.
  • Developed Financial Models comparing cost/charge variables for physician based test versus physician purchased test option.
  • Identified psychiatric hospital inpatient reimbursements for genetic testing related to psychosis disorders to determine optimal drug treatments.
  • Assisted client with assessing reimbursement and regulatory pathway options for biologic versus medical device.
  • Assisted multiple clients with presentations to HCPCS's Workgroup in support of new HCPC code development.
  • Coordinated multiple meetings between clients and CMS Coverage and Analysis Group to review clinical study protocols prior to commencement, thereby introducing client to CMS and to obtain preview of data requirements to support CMS coverage.
  • Settled jurisdiction issue between Medicare Durable Medical Equipment Regional Carriers (DMERCS) and Part B Carriers regarding benefit category classification for a pleural catheter and drainage supply products. Prior to intervention, products were not being paid by either entity. RPI forced the matter to resolution. Product is now being paid and patients are able to avoid hospitalizations for pleural effusion accumulation. RPI also assisted the client with applying for Medicare Part B provider status enabling the manufacturer to submit claims and receive direct payment from Medicare.
  • Developed reimbursement strategy for new prostate treatment device resulting in distribution agreement for early stage company with industry leader.
  • Successfully assisted multiple clients in submitting comments to CMS's proposed OPPS rule(s) regarding APC reassignment. These interventions resulted in assignment to more clinically and economically coherent APC assignments.
  • Facilitated venture capital funding for startup company by documenting successful reimbursement pathway for product under development.
  • Secured payment of prostate brachytherapy treatment in Ambulatory Surgery Center site of service. Prior to RPI's intervention, several local Medicare carriers were disallowing the procedure in the ASC setting. Worked with local Medicare Medical Directors to draft LCD policy for ASC site of service.
  • Recognized significant payment issue for physician reimbursement of brachytherapy seeds for prostate cancer therapy. HCPCS Code indicated by Medicare for use in billing brachytherapy seeds not payable under Part B. Successfully resolved payment problem by bring the issue to Medicare's attention and suggesting payment resolution which was ultimately accepted and implemented by Medicare.
  • Secured new CPT codes for shell vial laboratory technique for various viruses specific antigens.
  • Organized and ran multicenter clinical trial reimbursement for drug eluting stent.
  • Developed 2005 Heart Rhythm Society Coding Guide for Heart Rhythm Procedures and Services.
  • Facilitated strategic partner relationships by providing reimbursement guidance to corporate development executives.
  • Secured new HCPCS code with supporting payment for drug delivered through nebulizer.
  • Overturned noncoverage policy for radiofrequency tumor ablation procedures with Cigna, Blue Cross/Blue Shield of Texas, Illinois and New Mexico.
  • Secured CMS Pass Through Codes for various products (such as thrombectomy catheters, ocular implants, infrared imaging for blood perfusion changes, etc.) enabling the hospital outpatient department to receive additional reimbursement.
  • Developed on-line reimbursement training course for heart rhythm therapies used by sales reps and hospital/physician customers.
  • Overturned Medicare's noneligibility decision for Pass Through criteria for a transluminal thrombectomy retrieval device.
  • Successfully promoted the correct use of the KD modifier with Medicare contractors to enable consistent and routine payment for drugs infused through Durable Medical Equipment products. Prior to RPI's involvement, claims were paid erratically with low or no payment.

 

Presentations

  • Answering Investor Reimbursement Questions, MDMA Annual Reimbursement Conference, Washington DC, November 2007.
  • 2008 Changes in Payment for OPPS and ASC, AAOHNS (American Academy of Head and Neck Surgery), Washington DC, October 2007.
  • Introduction to Life Science Technology Transfer: Understanding Reimbursement for Healthcare Devices and Drugs, University of Colorado Health Science Center, BARD Center for Entrepreneurship, October 2007.
  • Reimbursement During Clinical Trials, Journal of Best Clinical Practices, San Diego, CA, 2007.
  • Understanding P4P and its Impact on Medicare: Medicare Advantage Congress, January 2007.
  • Liver Directed Radiotherapy with Microspheres, Second Annual Clinical Symposium, Scottsdale, Arizona, Coding and Billing for Microspheres.
  • Emerging Trends in Radioembolization using Microspheres, A Clinical Workshop, Chicago, Illinois, Reimbursement Guidelines for Microspheres.
  • Medical Management Systems Innovations Conference, American Board of Quality Assurance and Utilization Review Physicians (ABQAURP), Promoting Evidence Based Medicine.
  • 2007 Biobootcamp: Reimbursement and Strategic Partners; Colorado BioScience Association (CBSA).
  • National Institutes of Health (NIH): Reimbursement for Your Product or Service Developed Under SBIR/STTR
  • Regulatory Affairs Professionals Society (RAPS): Regulatory Issues that Can Make or Break Reimbursement
  • Medtech Insight—IN3; Reimbursement Throughout the Product Life Cycle
    * Association of Clinical Research Professionals (ACRP); Reimbursement in Medical Device Clinical Trials
  • BioEnterprise (Cleveland, OH); Understanding Reimbursement
  • Orange County Regulatory Affairs Discussion Group; Integrating Reimbursement in the Product Development Process
  • Journal of Clinical Research Best Practices; Reimbursement in Clinical Trials
  • Tech Coast Angels; Payers are Forcing Changes in the Goals of Clinical Trials

 

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