Value-Based Pricing: The Good, The Bad, and The Ugly
|
|
- Erin Marsh
- 5 years ago
- Views:
Transcription
1 Value-Based Pricing: The Good, The Bad, and The Ugly Medical Device Regulatory, Reimbursement and Compliance Congress March 27, 2008 Randel E. Richner, BSN, MPH President, Founder
2 Reform There is no problem, however difficult, which if we roll up our sleeves, we cannot completely ignore. --George Carlin
3 3 Policy Overview Technology Is Good. Technology per se, does not cause increased health care costs 1. It is only randomly possible to accurately detect the true value of technology due to a fragmented care delivery, migration of services, and system issues (complex overlay of private/public insurers to track and monitor care and value). Misaligned payment systems may cause perverse care incentives and artificial determinants of value. 2. The calculation of risk in determining the threshold of value is largely ignored.
4 4 New, Innovative and Complex Technologies Devices are getting smarter and are providing more information Intelligent devices Biotechnology Revolution Personalized Medicine Combination Products Information-Rich Therapeutics
5 Typical Market Development Early adopter Early Majority Late majority Introduce Disruptive Product Validate Launch post-fda Promote clinical utility Establish a network of advocates Position for Market Penetration Drive your message into the market Secure satisfactory reimbursement. Promote improved care Prove Principle Drive Adoption Change Standard
6 Innovation: PTCA % Penetration Length of Reign: Continuous improvement Unsatisfactory alternatives explored Upgrade to stents Uptake: Replaces CABG Moves procedure from OR to CCL Creates new medical specialty Intensity of adoption: Highly respected pioneer Decreased procedural costs Improves patient satisfaction Shortens LOS Time (in years)
7 Technology Assessment and Value
8 8 Technology Access Decision-Making Occurs at Multiple Levels Geographic Level Organizations Involved CMS, (Global--International) Major national third party payers and benefit managers National Regional Medicare Intermediaries and Carriers, DMERCs Regional health plans Local Medicaid administrators IDNs Physician groups Hospitals
9 9 FDA/CMS Divergencies Treatable Population FDA Label Indicated Population CMS Covered Population FDA regulator: public health/safety Safe products Assumes Market sorts out clinical value and comparative effectiveness Standards vary by risk CMS regulator: purchaser Improved health for good value Increased focus on clinical benefits blur into public health effort Decisions are broad, policy-based Uncertainties: How will CMS define and pay for incremental benefit? How long will full coverage of labeled indications take?
10 Evidence Development and Value Technology Assessment: Evidence Based Medicine: Coverage with Evidence Requirements Practice Based Management Pay for Performance Quality Outcomes Outcomes Assessment: Cost-Effectiveness Analsyis Outcomes Demonstration Projects Overuse, Underuse, Misuse Superior Medical outcomes Least Costly Alternative Substantial Equivalence Comparative Effectiveness
11 Type of data you collect depends on the category of product Similar to Another Product Expansion of Existing Technology Truly New and Innovative Evidence Required Usually FDA approval with same indications suffice for inclusion in existing coverage Publication of Controlled Studies (usually 1-2) Coverage under Protocol Publication of 2 4 RCTs with ongoing study through Registry Data, Cost-Effectiveness Data Evidence Should Prove Similar clinical efect and outcomes, cost-efficacy a plus for differentiation Incremental clinical and / or economic value of the device relative to its predicate Higher degree of certainty. RCTs show improved outcomes over other treatments, with lower costs Clinical Trial Data Types Necessary/ Optional Regulatory approval, Practical clinical trial, limited cost study RCTs, Costeffectiveness, Long-term outcomes, Ongoing Practical Clinical Trials RCTs, Costeffectiveness, Long-term outcomes, Practical Clinical Trial, Post-market registry
12 Payment Misalignments and determining Value
13 13 Medicare s s Complex Reimbursement Processes Each payment system has its own rules, based in statute, and uses data from the providers it pays Different payments in different sites for the same items or services Can create inappropriate incentives Providers learn to balance underpaid/overpaid services to achieve bottom-line Benefits of less invasive services, migration to less costly settings, not recognized in value calculations
14 14 Major CMS Payment Systems PROSPECTIVE PAYMENT SYSTEMS: Inpatient PPS Outpatient PPS Inpatient Rehab Long-term Care Hospital Inpatient Psych Skilled Nursing Facility Home Health FEE SCHEDULES: Physicians Ambulatory Surgical Centers Clinical Labs Durable Medical Equipment, Prosthetics & Orthotics Ambulance ESRD
15 15 Example of Payment Divergences Diagnostic Colonoscopy CPT million procedures performed in 2003 Payment Site Utilization OPPS $513 56% ASC $446 22% PFS-PE $177 6% physician fee schedule (PFS) practice expense (PE)
16 Home Hemodialysis provides great value; providers limit adoption VS. Major clinical benefits LVH, heart failure improvement Anemia Rehabilitation/QOL 15-25% annual savings potential ($10-17K of 70K costs) Kaiser promoting home dialysis
17 Daily home dialysis challenges Largest savings in hospital costs, which are part of a different budget (Part A vs. Part B) and are not realized by the dialysis provider
18 Risks
19 Consider Unique technology-specific issues Risk: should the level of evidence be the same for a new MRI test as for a new brain aneurysm stent? Operator Skill: How does one design the impact of physician enduser skills on patient outcomes and study design? Life Cycles: How do we expect to use traditional study approaches with minimum of 3 years from start to pubs when technology changes within a 2 years? Combinatorial science: How does the study account for the manufacturing changes (polymers, voltages, wires and metals, drugs) on the effect of patient outcomes? Physician end-user involvement: How are physicians mobilizing to determine the outcomes critical to study to determine value?
20 Drug Risks: Near-Term Fatalities Per Person-Year Log Scale Orders Of Magnitude Deaths per 100,000 person-years Smallpox vaccine Antihistamines Daily aspirin Clozapine Tysabri for MS Vioxx
21 Transportation Motorcycle: 450 Truck drivers: 45 Passenger car: Cell phones + driving: 1.3 Commercial airplane: Smallpox vaccine Antihistamines Daily aspirin Clozapine Tysabri for MS Vioxx Deaths per 100,000 person-years
22 Solution 1: Value New Study Paradigm. Encourage access, innovation Risk-based stratification of evidence Physician end-user involvement Focus on treatment comparisons rather than individual product comparisons Electronic records, and HIT advances; invest in this infrastructure. Gold standard, database, epidemiological studies Bayesian analysis: preexisting data are constantly adjusted using new data as acured: potential reduction of sample sizes, and ability to continually update probability of success or failure. Collaborate with NIH, AHRQ, Private, public entities. Global interactions and use of data
23 Solution 2: Reward the Future Reward preventative services and interventions that can clearly demonstrate a significant value over existing products. Integrate nanotechnology, IT, molecular diagnostics and combination therapies (drugs/devices) into existing payment schemas. Evaluate new medical technologies at CMS through the Council of Medical Technology and Innovation; adapt payment mechanisms. Use an episode of care as a reward technology that moves from acute to home setttings (works in Kaiser-like systems where physician payment is not linked to utilization; providers and payers are aligned) Include physician payments and incentives in the episode of care. PREEMPTIVE, PREDICTIVE, PERSONALIZED, and PARTICIPATIVE
24 Solution 3: Value includes Risk Avoid the temptation to regulate when events occur before the technology is tested thoroughly. Partner with industry and medicine on improved methods to accurately measure risk. Use FDA-critical path initiatives as model.
25 Progress in the leading technology of our time has been so dramatic that it has brought about, time and again, swift qualitative changes in the material world around us, change that surely cannot be expressed simply as variations in prices or quanities. Trajtenberg, Economist, 1990.
26 Founder & President: Randel E. Richner, BSN, MPH
Overview of Reimbursement Strategies for Novel Medical Technologies
Overview of Reimbursement Strategies for Novel Medical Technologies Nov 9, 2016 Goals and Objectives Develop understanding of U.S. medical technology reimbursement landscape and provide information about
More informationIntroduction to the Centers for Medicare & Medicaid Services (CMS) Payment Process
Introduction to the Centers for Medicare & Medicaid Services (CMS) Payment Process Thomas Barker, Foley Hoag LLP tbarker@foleyhoag.com (202) 261-7310 October 1, 2009 Overview Medicare Basics Paths to Medicare
More informationAgenda. National Coverage Determinations (NCDs) Opening a Review
Stuart Langbein Hogan & Hartson L.L.P. SMLangbein@hhlaw.com (202) 637 5744 1 Agenda Coverage Developments Choices for coverage reviews Lessons from coverage determinations Least costly alternative A look
More informationThe Fundamentals of Reimbursement
The Fundamentals of Reimbursement Understanding How Coverage, Coding, and Payment Impact a Medical Technology Kelli Hallas Executive Vice President of Reimbursement Emerson Consultants, Inc. OMTEC June
More informationPayment for Covered Services
A WellCare Company Payment for Covered Services Today s Options PFFS reimburses deemed (non-contracted) providers at 100% of the current Medicare-approved amount for all Medicare-covered services, less
More informationMarket Access Strategy and Planning: Succeeding in the Age of Value-based Reimbursement
Market Access Strategy and Planning: Succeeding in the Age of -based Reimbursement Presented by: Michael J. Lacey, Senior Director, Strategic Consulting (Life Sciences) Date: March 01, 2017 Truven Health
More informationThe Impact of Future Healthcare Reform on MedTech Communications
J. Robert Paulson President & CEO NxThera, Inc. The Impact of Future Healthcare Reform on MedTech Communications Perspectives From an Early-Stage Medical Device Company The Impact of Future Healthcare
More informationHospital Outpatient Prospective Payment System (OPPS) Based Payment Method
Hospital Outpatient Prospective Payment System (OPPS) Based Payment Method (Formerly the Highmark APC Based Payment Methods Manual) Provider Training Manual and Change Documentation Issued by: Payment
More informationHospital Outpatient Prospective Payment System (OPPS) Based Payment Method
Hospital Outpatient Prospective Payment System (OPPS) Based Payment Method (Formerly the Highmark APC Based Payment Methods Manual) Provider Training Manual and Change Documentation Issued by: Payment
More informationSeptember 14, Dear Administrator Verma:
September 14, 2018 Seema Verma Administrator Centers for Medicare and Medicaid Services Dept. of Health and Human Services Attention: CMS-1695-P P.O. Box 8013 Baltimore, MD 21244-1850 Re: CMS-1695-P; Medicare
More informationBlueOptions Prime EPO
BlueOptions Prime EPO Schedule of Benefits Plan 03768 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where more detailed
More informationHOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE
HOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) FREEDOM BLUE (A Medicare Advantage PPO) PROVIDER TRAINING MANUAL AND CHANGE DOCUMENTATION Table of Contents
More informationWHAT EVERY NEW PRACTITIONER SHOULD CONSIDER
WHAT EVERY NEW PRACTITIONER SHOULD CONSIDER January 24, 2017 Andrew N. Meyercord Gray Reed & McGraw 1601 Elm Street Suite 4600 Dallas, Texas 75201 214.954.4135 ameyercord@grayreed.com 129 attorneys Full-service,
More informationASSESSING THE VALUE OF MEDICAL DEVICES CHOOSING THE BEST PATH FORWARD: WHERE DO WE GO FROM HERE? Drew Baker GO FROM HERE?
ASSESSING THE VALUE OF MEDICAL DEVICES CHOOSING THE BEST PATH FORWARD: WHERE DO WE GO FROM HERE? An ISPOR Issue Panel by the Value Assessment of Medical Devices Working Group of the Medical Device and
More informationPATH TOWARD PAYMENTS THAT REWARD VALUE
PATH TOWARD PAYMENTS THAT REWARD VALUE David Muhlestein, PhD JD Chief Research Officer Leavitt Partners @DavidMuhlestein December 18, 2017 1 PRESENTATION OVERVIEW 1. Current Trends 2. Are ACOs Delivering
More informationBasics of Medicare Coverage and Payment. Tom Ault Health Policy Alternatives April 20, 2007
Basics of Medicare Coverage and Payment Tom Ault Health Policy Alternatives April 20, 2007 Two Pathways for Medicare Coverage Decisions National coverage decisions (NCDs( NCDs) Developed by CMS Only 10%
More informationThis Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your benefits can be found.
BlueOptions Schedule of Benefits Plan 03766 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where more detailed information
More informationSUBLUE AND SUORANGE: 2018 SCHEDULE OF BENEFITS -EMPLOYEE COST SHARING
Cost Sharing Definitions Annual Deductible 1 (amounts are not cumulative across levels) $100 per individual with a maximum of $250 for a family $300 per individual with a maximum of $1,000 for a family
More informationMedicare Comprehensive ESRD Care (CEC) Initiative
Medicare Comprehensive ESRD Care (CEC) Initiative May 2013 Avalere Health LLC Avalere Health LLC The intersection of business strategy and public policy Background On February 4, 2013, the Center for Medicare
More informationPre Market Reimbursement Strategies for New Technologies
Pre Market Reimbursement Strategies for New Technologies Marilyn Denegre-Rumbin, JD MBA Director Payer-Reimbursement Strategy Strategy & Business Development December 1, 2015 Early Strategy Integration
More informationHOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE
FreedomBlue HOSPITAL OUTPATIENT BILLING AND REIMBURSEMENT GUIDE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) FREEDOMBLUE (A Medicare Advantage PPO) Table of Contents Section I. Overview of APC Based Payment
More informationFCSRMC 2017 HEALTH SCHEDULE OF BENEFITS
FCSRMC 2017 HEALTH SCHEDULE OF BENEFITS BlueOptions Plan 05772 Important things to keep in mind as you review this Schedule of Benefits: This Schedule of Benefits is part of your Benefit Booklet, where
More informationHighmark. APC Based Payment Methods
Highmark APC Based Payment Methods Provider Training Manual and Change Documentation Issued by: Provider Reimbursement Decision Support & Systems Implementation Table of Contents Section I. Overview of
More informationINSTITUTE OF MEDICINE COMMITTEE ON THE DETERMINATION OF ESSENTIAL HEALTH BENEFITS
COMMENTS 1310 G Street, N.W. Washington, D.C. 20005 202.626.4780 Fax 202.626.4833 Before the INSTITUTE OF MEDICINE COMMITTEE ON THE DETERMINATION OF ESSENTIAL HEALTH BENEFITS On How Insurers Make Determinations
More informationAttachment C - Schedule of Benefits. PremierBlue Plan A52
- Schedule of Benefits PremierBlue Benefit percentages apply to the BCBST Maximum Allowable Charge. Network level applies to services received from Network Providers and Non-Contracted Providers. Out-of-Network
More informationUnitedHealthcare Choice Plus. United HealthCare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus United HealthCare Insurance Company Certificate of Coverage For the Definity Health Savings Account (HSA) Plan 7PC of East Central College Enrolling Group Number: 711369 Effective
More informationSummary of Medicare Provisions in the President s Budget for Fiscal Year 2016
February 2015 Issue Brief Summary of Medicare Provisions in the President s Budget for Fiscal Year 2016 Gretchen Jacobson, Cristina Boccuti, Juliette Cubanski, Christina Swoope, and Tricia Neuman On February
More informationMEDICAL DEVICE REIMBURSEMENT PRESENTED AT ST. THOMAS UNIVERSITY, DESIGN AND MANUFACTURING IN THE MEDICAL DEVICE INDUSTRY COURSE ON SEPTEMBER 30, 2013
MEDICAL DEVICE REIMBURSEMENT PRESENTED AT ST. THOMAS UNIVERSITY, DESIGN AND MANUFACTURING IN THE MEDICAL DEVICE INDUSTRY COURSE ON SEPTEMBER 30, 2013 Presented by: Michael A. Sanchez, M.A., CCA Principal
More informationCentral Health Medicare Plan (HMO)
Central Health Medicare Plan (HMO) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? How much is the deductible? Is there any limit on how
More informationThe following is a description of the fields that appear on the results page for the Procedure Code Search.
Fee Schedule Legend Updated: 11/6/17 The following is a description of the fields that appear on the results page for the Procedure Code Search. Procedure Code the five-character procedure code as listed
More informationForward Looking Statements
MAY 2016 [ 1 ] Forward Looking Statements SPECIAL NOTE REGARDING FORWARD-LOOKING STATEMENTS In addition to historical information, this presentation contains forward-looking statements with respect to
More informationSUPRO: 2018 SCHEDULE OF BENEFITS - EMPLOYEE COST SHARING
SU Pro (In- and Out-of-) In - Out -of- Cost Sharing Definitions Annual Deductible 1 Coinsurance Annual Out-of-Pocket Maximum 2 $200 per individual with a maximum of $400 for a family 5% of allowable amount
More informationThe Changing Landscape of Medicare's Clinical Trial Coverage Policies for Medical Devices. Michael Sanchez, M.A., CCA Reimbursement Advisor
The Changing Landscape of Medicare's Clinical Trial Coverage Policies for Medical Devices Michael Sanchez, M.A., CCA Reimbursement Advisor Disclaimer The reimbursement information provided in this presentation
More informationClinical Trials Corporate Medical Policy
Clinical Trials Corporate Medical Policy File name: Clinical Trials File code: UM.GEN.02 Origination: 12/31/2013 Last Review: 03/2017 Next Review: 03/2018 Effective Date: 06/01/2017 Description This medical
More information(1) Ambulatory surgical center (ASC) means any center, service, office facility, or other entity that:
.1 Definitions. Subtitle 09 WORKERS' COMPENSATION COMMISSION 14.09.08 Guide of Medical and Surgical Fees Authority: Labor and Employment Article, 9-309, 9-663 and 9-731, Annotated Code of Maryland Effective
More informationClick this button to place your order.
2018 Medicare 35th Edition What you need to know about Medicare in simple, practical terms. Click this button to place your order. 2018 MEDICARE CONTENTS 1 2 3 4 5 6 Published By PAGE INTRODUCTION Are
More informationMedicare Program; Medicare Shared Savings Program: Accountable Care Organizations Proposed Rule
701 Pennsylvania Ave., NW, Suite 800 Washington, DC 20004-2654 Tel: 202 783 8700 Fax: 202 783 8750 www.advamed.org February 6, 2015 Marilyn Tavenner, Administrator Centers for Medicare & Medicaid Services
More informationGlossary. Adults: Individuals ages 19 through 64. Allowed amounts: See prices paid. Allowed costs: See prices paid.
Glossary Acute inpatient: A subservice category of the inpatient facility clams that have excluded skilled nursing facilities (SNF), hospice, and ungroupable claims. This subcategory was previously known
More informationPage 1 of 8 Printed on 1/28/2015
Cost Sharing - Member's Responsibility Deductible (DED) (Per Person/Family Aggregate) $5,000 / $10,000 $1,000 / $3,000 $2,000 / $6,000 Out-of-Network $10,000 / $30,000 $3,000 / $6,000 $6,000 / $18,000
More informationEvidence-Based Program Reimbursement Strategies. Timothy P. McNeill, RN, MPH
Evidence-Based Program Reimbursement Strategies Timothy P. McNeill, RN, MPH 1 Medicare & Value Based Purchasing 2 Medicare Advantage Changes 3 DSMT Requirements 4 CDSME Tip Sheet Opportunities for EB Programs
More informationMedical Technology Industry. Richard Price, V.P. Payment and Health Care Delivery Policy The Advanced Medical Technology Association
Health Care Reform and the Medical Technology Industry Richard Price, V.P. Payment and Health Care Delivery Policy The Advanced Medical Technology Association (AdvaMed) AdvaMed World s largest medical
More informationDELIVERING HIGHER-VALUE MATERNITY CARE
DELIVERING HIGHER-VALUE MATERNITY CARE Designing Alternative Payment Models for Better Care, Lower Spending, and Financially Viable Maternity Care Providers Harold D. Miller President and CEO Center for
More informationPHASE II OF THE FINAL STARK REGULATIONS: WHAT DO THEY MEAN FOR HEALTHCARE PROVIDERS
Kean Miller Health Care Industry Business Group PHASE II OF THE FINAL STARK REGULATIONS: WHAT DO THEY MEAN FOR HEALTHCARE PROVIDERS April 28, 2004 Linda G. Rodrigue, Esq. and Clay J. Countryman, Esq. Kean,
More informationHealth Net 2009 PEARL PLAN NATIONAL PRIVATE FEE-FOR-SERVICE REINBURSEMENT GRID
Health Net 2009 PEARL PLAN NATIONAL PRIVATE FEE-FOR-SERVICE REINBURSEMENT GRID Acute Care Hospital Inpatient Services These hospitals are paid a diagnosis-related group (DRG) amount using the Medicare
More information02-03 FORM CMS
3527 FORM HCFA 2540-96 01-01 3527. WORKSHEET C - RATIO OF COST TO CHARGES FOR ANCILLARY OUTPATIENT COST CENTERS This worksheet computes the ratio of cost to charges for ancillary services and, for costs
More informationS E C T I O N. National health care and Medicare spending
S E C T I O N National health care and Medicare spending Chart 6-1. Medicare made up about one-fifth of spending on personal health care in 2002 Total = $1.34 trillion Other private 4% a Medicare 19%
More informationCompensation Paid by Healthcare Providers
Compensation Paid by Healthcare Providers Physician compensation continues to be an especially important issue due to extensive integration of medical practices into larger healthcare systems and the severe
More informationStrategic Purchasing of Medical Devices
Strategic Purchasing of Medical Devices James C. Robinson Leonard D. Schaeffer Professor of Health Economics Director, Berkeley Center for Health Technology University of California, Berkeley Overview
More informationHealthcare Reform and Its Impact on the Care Delivery System
Healthcare Reform and Its Impact on the Care Delivery System Agenda 1) The Era of Healthcare Reform 2) Healthcare Reform and Post-Acute Care 3) Succeeding in the Reform Era: Managing the Continuum of Health
More informationContents. Page. Chapter
Contents Chapter I. Summary and Policy Options........................................ 3 2. Physician Payment Under the Medicare Program: Problems and Changing Context...................................................
More informationSUMMARY PLAN DESCRIPTION SAMPLE COMPANY
This document is a sample of the basic terms of coverage under a Choice Plus product. Your actual benefits will depend on the plan purchased by your employer. SUMMARY PLAN DESCRIPTION COMPANY 0000-000000
More informationOPPS Overview AHLA March 2013
OPPS Overview AHLA March 2013 Carrie Bullock Deputy Director, Division of Outpatient Care Hospital & Ambulatory Policy Group Center for Medicare CMS Disclaimer This presentation was prepared by Ms. Bullock
More informationProviders Contracting Directly With Employers
Providers Contracting Directly With Employers NOVEMBER 14, 2018 1 The Current Model 2 Direct-to-Employer (DTE) Health Plan Aligned Incentives Gain Share Direct Relationship At The Table Integrated Data
More informationRedefining Health Care: Creating Value-Based Competition on Results
Redefining Health Care: Creating Value-Based Competition on Results Presentation by Professor Michael E. Porter Harvard Business School New Models of Health Care Boston, MA April 12 th, 2005 This presentation
More informationbenefits Summary of BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida
2016 Summary of benefits BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida Florida Blue is a trade name of Blue Cross and Blue Shield of Florida Inc., an Independent
More informationSurgery required as the result of Morbid Obesity* INDIVIDUAL CALENDAR YEAR MAXIMUMS Acupuncture $2,000 Chiropractic Care $2,000
AMHIC, A Reciprocal Association Effective January 1, 2019 Important Note: Do not rely on this chart alone. It is only a summary. The contents of this summary are subject to the provisions of the Benefit
More informationHEALTH ECONOMICS AND REIMBURSEMENT
HEALTH ECONOMICS AND REIMBURSEMENT VASCULAR CY 2016 MEDICARE PHYSICIAN FEE SCHEDULE (PFS) UPDATE Abbott Vascular is pleased to provide you with this summary of the Medicare Physician Fee Schedule (PFS)
More informationTHE LINK BETWEEN FDA APPROVAL OF MEDICAL DEVICES AND REIMBURSEMENT
1 THE LINK BETWEEN FDA APPROVAL OF MEDICAL DEVICES AND REIMBURSEMENT Association of Corporate Counsel Legal Quick Hit September 6, 2011 Maria E. Gonzalez Knavel Partner Foley & Lardner LLP 414.297.5649
More informationHealth Information Technology and Management
Health Information Technology and Management CHAPTER 9 Healthcare Coding and Reimbursement Pretest (True/False) CPT-4 codes are used to bill for disease and illness. Medicare Part B provides medical insurance
More informationSHL Solutions PPO 25/750/80%
SHL Solutions PPO 25/750/80% Attachment A Benefit Schedule Lifetime Maximum Benefit for all Covered Services: Unlimited. Calendar Year Deductible (CYD): Your CYD is $750 of EME per Insured and $1,500 of
More informationMarket Trends: Volume to Value. Payment for dialysis access procedures in 2016 and beyond. Controlling costs. Fee for Service Coding Changes
Market Trends: Volume to Value Reimbursement is changing from payments based on fee-for-service (FFS) (volume) to a more value-based system and will shift some risk from payors to providers. Payment for
More information21% Total Medicare Beneficiaries (2017): 58 million
About 1 in 5 Medicare beneficiaries are receiving care from ACOs or medical home models in 2017 Medicare Advantage: 19 million beneficiaries 33% 21% ACOs and Medical Homes 12 million beneficiaries Traditional
More informationUnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company of Illinois. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company of Illinois Certificate of Coverage For the Plan J4Z of YWCA of Metropolitan Chicago Enrolling Group Number: 742540 Effective Date: July
More informationSummary of Benefits. for Anthem MediBlue Select (HMO) Available in Hartford county, CT
Summary of Benefits for Available in Hartford county, CT Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal.
More informationCoverage Expansion [Sections 310, 323, 324, 341, 342, 343, 344, and 1701]
Summary of the U.S. House of Representatives Health Reform Bill October 2009 The following summarizes the major hospital and health system provisions included in the U.S. House of Representatives health
More informationSUMMARY OF BENEFITS. Unlimited. Lifetime Maximum Applies to all Part A and Part B expenses. Unlimited
SUMMARY OF BENEFITS Connecticut General Life Insurance Company For Retirees of Colby College Plan Name: Medicare Surround Custom Plan Effective: January 1, 2018 through December 31, 2018 Lifetime Maximum
More informationSUMMARY OF BENEFITS. Cigna Health and Life Insurance Co.
SUMMARY OF BENEFITS Ohio Associated Enterprises Health Savings Account Open Access Plus www.mycigna.com Member Services: (866) 494-2111 Cigna Health and Life Insurance Co. General Services In-Network Out-of-Network
More informationReimbursement Update Conference. Trends in Coverage and Reimbursement Policies Implications to MedTech Companies
Reimbursement Update Conference Trends in Coverage and Reimbursement Policies Implications to MedTech Companies David Barone Boston MedTech Advisors www.bmtadvisors.com September 2011 1 Boston MedTech
More informationSummary of Benefits. for CareMore ESRD (HMO SNP) Available in San Bernardino County (partial) SBSBESRD16 Y0114_16_081547A CHP CMS Accepted ( )
Summary of Benefits for CareMore ESRD (HMO SNP) Available in San Bernardino County (partial) SBSBESRD16 Y0114_16_081547A CHP CMS Accepted (08222015) Summary of Benefits January 1, 2016 - December 31, 2016
More informationSolutions for the end-of-chapter questions and problems PowerPoint slides covering the essential issues of each chapter Test bank
This is a sample of the instructor materials for Louis C. Gapenski and Kristin L. Reiter, Healthcare Finance: An Introduction to Accounting and Financial Management, Sixth Edition. The complete instructor
More information2015 Benefits Overview
2015 Benefits Overview ASPIRE HEALTH ADVANTAGE VALUE (HMO) BENEFIT Monthly Plan Premium Out-of-Pocket Limit (In-Network Medicare-covered benefits) Annual Part C Deductible (all services except for Prescription
More informationMedTech Innovation Amid Changing Dynamics for Insurers, Hospitals, and Consumers
MedTech Innovation Amid Changing Dynamics for Insurers, Hospitals, and Consumers Deutsche Bank Medtech Boot Camp March 21, 2016 James C. Robinson Leonard D. Schaeffer Professor of Health Economics Director,
More informationSummary of Benefits Boone County
Summary of Benefits 2017 Boone County Y0027_16-093_EN CMS Accepted 08/30/2016 Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It
More informationMedicare Part D: Better understanding the nuances of the prescription drug benefit
Medicare Part D: Better understanding the nuances of the prescription drug benefit Rajul A. Patel, Pharm.D, Ph.D. TJL School of Pharmacy & Health Sciences University of the Pacific July 26 th, 2018 Today
More informationUnitedHealthcare Choice Plus. UnitedHealthcare Insurance Company. Certificate of Coverage
UnitedHealthcare Choice Plus UnitedHealthcare Insurance Company Certificate of Coverage For the Plan 21D of Big Walnut Local School District Enrolling Group Number: 753271 Effective Date: January 1, 2016
More informationOPPS Rules for ASCs. Learning Objectives
OPPS Rules for ASCs Coding or Reimbursement Rules? 1 Learning Objectives The significance of OPPS as reimbursement policy and how this differs from coding policy Medicare Benefit Policy Manual Guidance
More informationI. PLAN DESCRIPTIONS. A. POS Point of Service
I. PLAN DESCRIPTIONS A. POS Point of Service The Partnership Plan offers a single point of service plan to provide healthcare services both within and outside a defined network of Providers. No referrals
More informationPrecision Medicine. A Health Economic perspective
Precision Medicine. A Health Economic perspective Lieven Annemans Ghent University Lieven.annemans@ugent.be April 2018 1 Exponential technology exponential cost? http://medicalfuturist.com 2 Total public
More informationMerit-Based Incentive Payment System (MIPS): ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) Measure
Merit-Based Incentive Payment System (MIPS): ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) Measure Measure Information Form 2019 Performance Period 1 Table of
More informationOutpatient Prescription Drug Benefits
Outpatient Prescription Drug Benefits Supplement to Your HMO/POS Evidence of Coverage Summary of Benefits Member Calendar Year Brand Drug Deductible Per Member Applicable to all covered Brand Drugs, including
More informationMemorial Hermann Advantage (PPO)
Memorial Hermann Advantage (PPO) INTRODUCTION TO SUMMARY OF BENEFITS January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
More informationThe HPfHR 3-Tier System
The HPfHR 3-Tier System The basic level (Tier 1) of the new healthcare system would cover the entire population- from cradle to grave and would include, based on evidenced based data, all medical, surgical
More informationCigna Administrative Policy
Cigna Administrative Policy Subject Clinical Trials Table of Contents Administrative Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 4 Effective Date... 1/15/2014 Administrative
More informationChapter 5: Billing on the CMS 1500 Claim Form
Chapter 5: Billing on the CMS 1500 Claim Form Introduction The CMS 1500 claim form is used to bill for non facility services, including professional services, freestanding surgery centers, transportation,
More informationRe: Medicare Prescription Drug Benefit Manual Draft Chapter 6
September 26, 2006 BY ELECTRONIC DELIVERY Cynthia Tudor, Ph.D. Director, Medicare Drug Benefit Group Centers for Medicare & Medicaid Services Mail Stop C4-13-01 7500 Security Boulevard Baltimore, MD 21244
More informationBayesian Analysis: Bayesian Analysis in Health Economics Bayesian Analysis: Posterior Interval Bayesian Analysis: Prior Distribution
Bayesian Analysis Bayesian Analysis Bayesian Analysis Bayesian Analysis Biotechnology Biotechnology Biotechnology Bootstrapping Case Mix Index Clinical Practice Guidelines Study Bias Study Bias Study Bias
More informationbenefits Summary of BlueMedicare SM HMO A Medicare Advantage HMO Plan Broward County
2016 Summary of benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Broward County Florida Blue HMO is the trade name of Health Options, an HMO affiliate of Florida Blue. These companies are Independent
More informationIntroduction to Pharmacoeconomics. Almut G. Winterstein, Ph.D.
Introduction to Pharmacoeconomics Almut G. Winterstein, Ph.D. Why do we need Health Economics? Suppose you are comparing two drugs or services where one is more expensive than the other. In choosing the
More informationCDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO)
Introduction to the Summary of Benefits Report for CDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO) January 1, 2015 December 31, 2015 CAPITAL REGION OF NEW YORK STATE
More informationBlue Shield of California Life & Health Insurance Company
Blue Shield of California Life & Health Insurance Company Outpatient Prescription Drug Benefit Rider Insurance Certificate Outpatient Prescription Drug Benefit Summary of Benefits Insured Calendar Year
More informationMemorial Hermann Advantage (HMO)
Memorial Hermann Advantage (HMO) INTRODUCTION TO SUMMARY OF BENEFITS January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
More informationSummary of Benefits. BlueMedicare SM HMO A Medicare Advantage HMO Plan. Miami-Dade County. Y0011_ CMS Accepted
2015 Summary of Benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Miami-Dade County Y0011_32459 0814 CMS Accepted (HMO) Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives
More informationFrom Research to Revenue Coverage and Reimbursement for Life Sciences Products
From Research to Revenue Coverage and Reimbursement for Life Sciences Products Coverage and Reimbursement Considerations for In Vitro Diagnostics Demetrios L. Kouzoukas, Anna D. Kraus, and Katherine Sauser,
More informationSummary of Benefits. for CareMore Touch (HMO SNP) Available in Los Angeles and Orange Counties (partial)
Summary of Benefits for CareMore Touch (HMO SNP) Available in Los Angeles and Orange Counties (partial) SBLAOCTCH15 Y0017_15_081476A CHP CMS Accepted (09082014) Section I: Introduction to Summary of Benefits
More informationSummary of Benefits. for Anthem MediBlue Select (HMO) Available in Hartford county, CT
Summary of Benefits for Available in Hartford county, CT Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal.
More informationMedicare payment policy and its impact on program spending
Medicare payment policy and its impact on program spending James E. Mathews, Ph.D. Deputy Director, Medicare Payment Advisory Commission February 8, 2013 Outline of today s presentation Brief background
More informationPayment Policy: Code Editing Overview Reference Number: CC.PP.011 Product Types: ALL Effective Date: 01/01/2013 Last Review Date: 06/28/2018
Payment Policy: Code Editing Overview Reference Number: CC.PP.011 Product Types: ALL Effective Date: 01/01/2013 Last Review Date: 06/28/2018 Coding Implications Revision Log See Important Reminder at the
More informationFor Large Groups Health Benefit Plan 03359
Summary of Benefits for Covered Services Office Services Physician Office Services Family Physician Specialist Office Visit e-office Visit e-office Visit Advanced Imaging Services (AIS) (MRI, MRA, PET,
More informationSTATEMENT OF MANAGERS FOR THE MEDICARE, MEDICAID, AND SCHIP BENEFITS IMPROVEMENT AND PROTECTION ACT OF 2000
STATEMENT OF MANAGERS FOR THE MEDICARE, MEDICAID, AND SCHIP BENEFITS IMPROVEMENT AND PROTECTION ACT OF 2000 TITLE II - RURAL HEALTH CARE IMPROVEMENTS SUBTITLE A - CRITICAL ACCESS HOSPITAL PROVISIONS Section
More informationCoverage of IDE Clinical Trial Costs: Navigating the Medicare Maze
Coverage of IDE Clinical Trial Costs: Navigating the Medicare Maze by Jeffrey D. Zigler, JD 12 November 2011 Regulatory professionals recognize the value of clinical research in the medical device development
More information