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Reimbursement Basics For Life Science Entrepreneurs

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Edward Berger
Edward Berger

This document discusses key factors to consider when developing a reimbursement strategy for a new biomedical technology or therapeutic. It outlines three main elements of third-party payment - coding, coverage, and reimbursement. Coding identifies the service or item, while coverage determines if and when it will be paid for. Reimbursement specifies the payment methodology and amount. The document emphasizes the importance of collecting comprehensive clinical and cost data to demonstrate a technology's value to insurers and influence reimbursement decisions. Developing an effective reimbursement strategy requires understanding payer perspectives and coordinating regulatory and reimbursement processes early in product development.

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Evaluating a Biomedical Business Concept April 14, 2011 Edward E. Berger, Ph.D. REIMBURSEMENT BASICS FOR LIFE SCIENCE INVESTORS AND ENTREPRENEURS
THE REIMBURSEMENT CHALLENGE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
THE GOOD NEWS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
THE FIRST CRITICAL DIMENSION: BILLABLE SERVICE OR EXPENSE LINE ,[object Object],[object Object],[object Object],[object Object],[object Object]
THE SECOND CRITICAL DIMENSION: WHO PAYS? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
THIRD PARTY PAYMENT: THREE DISTINCT BUT RELATED ELEMENTS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CODING IS THE MOST COMPLEX OF THE THREE – AND THE LEAST IMPORTANT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
NEED A WELL DESIGNED AND EXECUTED CODING STRATEGY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COORDINATE PHYSICIAN AND FACILITY CODING (AND PAYMENT) STRATEGIES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COVERAGE POSES MORE DIFFICULT CHALLENGES (1) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COVERAGE POSES MORE DIFFICULT CHALLENGES (2) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COVERAGE DECISIONS ARE DATA DRIVEN ,[object Object],[object Object],[object Object],[object Object],[object Object]
PLAN TO MEET DATA REQIREMENTS FOR COVERAGE ,[object Object],[object Object],[object Object],[object Object],[object Object]
COORDINATE CMS / FDA PROCESSES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PRIVATE INSURER PERSPECTIVES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COVERAGE DECISION MAY TAKE TIME ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COVERAGE POLICIES ARE INCREASINGLY REFINED ,[object Object],[object Object],[object Object],[object Object]
COVERED SERVICES GET REIMBURSED BUT HOW MUCH? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PROVIDERS CAN NEGOTIATE WITH PRIVATE INSURERS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MEDICARE PAYS UNDER FIXED RULES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
MEDICARE PAYMENT SYSTEMS CHARACTERISTICS ,[object Object],[object Object],[object Object],[object Object],[object Object]
HOSPITALS AND PHYSICIAN GROUPS KNOW THE FINANCIAL SCORE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
DIRECT ECONOMIC IMPACT DOESN’T EXPLAIN EVERYTHING ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
INFORMATION IS THE KEY TO OPTIMIZING REIMBURSEMENT ,[object Object],[object Object],[object Object],[object Object]
BUILD A ROBUST RESEARCH CAPABILITY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
AGGRESSIVELY PLAN AND MANAGE YOUR REIMBURSEMENT STRATEGY ,[object Object],[object Object],[object Object],[object Object],[object Object]
Edward E. Berger, Ph.D. Larchmont Strategic Advisors 2400 Beacon St., #203 Chestnut Hill, MA 02467 Tel: 617-645-8452 Email: [email_address] Thank You

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Reimbursement Basics For Life Science Entrepreneurs

  • 1. Evaluating a Biomedical Business Concept April 14, 2011 Edward E. Berger, Ph.D. REIMBURSEMENT BASICS FOR LIFE SCIENCE INVESTORS AND ENTREPRENEURS
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  • 27. Edward E. Berger, Ph.D. Larchmont Strategic Advisors 2400 Beacon St., #203 Chestnut Hill, MA 02467 Tel: 617-645-8452 Email: [email_address] Thank You