How to Work with Private Payors to Grow the Mary Corkins, The Reimbursement Group

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
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Case Management Services are the driver of all other Commercial Payor efforts
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Every un‐appealed DENIAL is a precedent for future denials
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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
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Specific Support for your customers on a
case-by-case basis
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Ensure compliance with labeling
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Authorization for rendered services
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Treatment Management
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Clinician to clinician contact regarding
patient care
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HIPAA Compliance
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Adherence to Federal Mandates
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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
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Expert product
knowledge and
communication of support
materials
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Benefits & Claim
Adjudication
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Health Economics
Support Clinical decisionmaking
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Chart Reviews (CMS)
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Support the ‘processes’
Work the system
Engage Prescriber
Engage Payor
Payor
Facility
Physician
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Supports product pursuant to FDA labeling
Product specific telephonic response to incoming
inquiries, requests, and needs, by Nurse professionals
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Coding Guidance by certified medical coders
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Pre-Cert/Prior Authorization Services
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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
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Fewer denials means the PROCESS gets easier
over time
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Fewer “lost” accounts due to “Reimbursement
issues”
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Increased customer loyalty
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Pull-through days decrease by about 2-4 wks
TRG Results:
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Target physician participation between 20-35% of your
prescriber base
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Case Management should only be needed for 12-36 months
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<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