How to Work with Private Payors to Grow the Market for Your Product: The Case Management Argument Presented by: Mary Corkins, The Reimbursement Group (888) 440‐4TRG www.trgltd.com ` Case Management Services are the driver of all other Commercial Payor efforts ` Every un‐appealed DENIAL is a precedent for future denials ` Case Management Services provide a national snap‐ shot of how Payors are responding to your product We must either find a way or make one. -- Hannibal ` Specific Support for your customers on a case-by-case basis ` Ensure compliance with labeling ` Authorization for rendered services ` Treatment Management ` Clinician to clinician contact regarding patient care ` HIPAA Compliance ` Adherence to Federal Mandates ` Knowledge of various Plan requirements At first laying down, as a fact fundamental, New opinions are always suspected, and usually opposed, without any other reason but because they are not already common. -John Locke, Essay on Human Understanding • • • Expert product knowledge and communication of support materials • Benefits & Claim Adjudication • Health Economics Support Clinical decisionmaking • Chart Reviews (CMS) • Support the ‘processes’ Work the system Engage Prescriber Engage Payor Payor Facility Physician ` ` Supports product pursuant to FDA labeling Product specific telephonic response to incoming inquiries, requests, and needs, by Nurse professionals ` Coding Guidance by certified medical coders ` Pre-Cert/Prior Authorization Services ` Appeals & Denials Management I am a great believer in luck, and I find the harder I work the more I have of it. --Stephen Leacock The brain is a wonderful organ. It starts working when you get up in the morning, and doesn't stop until you get to the office. --Robert Frost • Fewer denials means the PROCESS gets easier over time • Fewer “lost” accounts due to “Reimbursement issues” • Increased customer loyalty • Pull-through days decrease by about 2-4 wks TRG Results: • Target physician participation between 20-35% of your prescriber base • • • Case Management should only be needed for 12-36 months • • • • <20% means you’re not impacting the market >35% means you may be slowing sales It is intended to bridge the gap between physician adoption and payor plan recognition It MUST be partnered with formal Policy development efforts Allow 6 mos activity before you can direct efforts Appropriately trained Case Managers yield approximately a 50% increase in Payor ‘approvals’ The Reimbursement Group (TRG) Mary Corkins, MBA, CPC President, The Reimbursement Group (888) 440-4TRG [email protected] www.trgltd.com