Reimbursement Landscape Assessment

Success in the marketplace depends on developing (and executing) a systematic reimbursement and market access strategy as early as possible.
Knowing whether to go for a national coverage (NCD), regional Medicare Administrative Contractors (MACs), or a payer roadshow (and which ones to approach first) is a multi-faceted decision pathway based on type of product, the ability of the available evidence to meet payer-specific thresholds, and the quantity of specific types of evidence, among many other factors.
Different reimbursement pathways carry different levels of risk and cost; having a plan informed by reimbursement experts and payer intelligence is a critical part of a market access plan.

Regulatory approval nor coding by itself guarantees reimbursement. Reimbursement is a 3-legged stool: coding, coverage, and payment. Payers make coverage and payment determinations through Health Technology Assessments (HTA) – and in the US, there is no universally set standard for HTA; every payer has their own process.
Support from key opinion leaders (KOLs) is instrumental to reimbursement.
Alternative pricing and payment models are taking off. As payers update their policies each year, there continues to be more and more transition from the traditional fee-for-service model to a value-based system.

If you’re unfamiliar with the US healthcare reimbursement system, our experts can provide you with a reimbursement landscape – a high-level overview of reimbursement (coding, coverage and payment) in the US – explaining how it pertains to your product and the need for all elements to come together for consistent reimbursement.
If you’re already familiar with the reimbursement system(s) within your target marketplace(s) and would like to understand how your product fits into the general landscape, our experts can conduct a reimbursement review with considerations for future reimbursement.
If you require support in developing a successful reimbursement strategy, our experts can conduct reimbursement assessments, or review findings from existing assessments, and build payer advisory boards comprised of current and former medical policy influencers to develop, assess, and/or validate your strategy. Reimbursement assessments and advisory boards can also identify appropriate sources of coverage, define elements of reimbursement (coding, coverage, and payment), define potential reimbursement pathways, and refine payer implementation timelines for your technology.

Insights

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