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To Code Or Not To Code? A Case Study

Note: This Case Study is based on the workshop that can be found here: https://www.akrosadvisory.com/akademy


Table of Contents: 

I.) Workshop Introduction 

II.) To Code 

III.) Not to Code 

IV.) Which is the right option?  

 

I) Workshop Introduction 

The “To Code or Not to Code” workshop was presented by Demi Radeva, CEO and Chief Strategist of Akros Advisory Services, and Rebecca Lanquist, owner of Horizon Reimbursement Consulting, LLC. The workshop described specific reimbursement pathways, including traditional and non-traditional pathways, while also providing clarity on reimbursement codes. Additionally, the workshop presented specific case studies to demonstrate what traditional reimbursement may look like compared to non-traditional. Demi Radeva has a decade of experience in strategy and innovation, and business development with UnitedHealthcare. Demi created Akros to help startups accelerate their Go-To-Market (GTM) strategies. Rebecca Lanquist has extensive experience working on strategy in the medical device field, and reimbursement consulting experience.  

 

II) To Code: Key Takeaways 

Reimbursement requires coding, coverage, and payment: 

Coding

The common procedure or device description used by healthcare professionals to submit to health insurance.

Coverage

A determination in which the procedure may or may not be allowed for different population and clinical circumstances.

Payment

The contracted rate or methodology associated with a special service or product rendered by a provider.

There are several reasons to code, including: 

1.) If you don’t rule out the traditional funding pathway, it could continue to come up 

2.) Your solution could be unique and warrant a new code 

3.) Codes are essential to payment analysis 

4.) There may be rules applying to the codes for your solution that are part of the traditional funding mechanisms 

 

Case Study: Dexcom 

Dexcom, a medical device with a fully mobile glucose monitoring system, had to jump through several hoops to gain reimbursement. The reason they came across difficulties to reimbursement was due to the mobile application they had in combination with the medical device. While private payers did cover this device, there was limited Medicare coverage and Dexcom had originally not qualified for a Medicare code. Eventually they qualified for a code with a receiver only, and eventually then qualified for a Medicare code with receiver and a smart phone.   

 

III) Not to Code: Key Takeaways 

There are several reasons to not code, including: 

1.) A code is unapplicable for the solution 

2.) The reimbursement rates are insignificant for the services 

3.) It is expensive  

4.) It can be a timely experience in trying to get a code 

 

”The reimbursement landscape is changing so we are always on top of the latest and greatest thing” – Demi Radeva, CEO & Chief Strategist at Akros Advisory Services 

 

Case Study: Doula

Doula care is an example of how services can vary by benefit and technology type when it comes to reimbursement. Doula is not necessarily a clinical service but supports healthcare needs and has supporting evidence regarding ROI. Doula reimbursement varies largely by state, with some states providing Medicaid coverage. Some insurance companies are partnering with doula networks to provide covered doula services. The overall takeaway regarding doula services is that reimbursement can vary from state-to-state, by health insurance company, by employer, and provider. This exemplifies that there are numerous non-traditional pathways to reimbursement that could be useful for solutions that don’t have existing codes. 

 

IV) Which is the right option? 

It is important to understand all the funding models for digital health technology companies prior to deciding on which is the right option (click to expand):   


Traditional Funding Model

  • Insurance companies reimburse codes (direct or indirect / bundled or fee for sevice)

  • Insurance companies give financial incentives and penalties

Alternative Funding Model

Non-Traditional Funding Model

 

When deciding whether coding or not coding is right for you, there are several points to think through first. The initial step would be to rule out existing codes, and once that is complete you could either consider a new code or analyze alternative reimbursement pathways. Both these steps can be useful to work through with an expert in these spaces.


A reimbursement assessment can help guide you in determining which step is best*: 

 

*NOTE: This is not an exhaustive list, it serves as a foundation assessment to provide minimum understanding before taking the next step. 

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