REIMBURSEMENT

GM Associates is the nationally recognized leader in reimbursement strategic planning and problem solving for pharmaceutical, medical device, wound care, and biotechnology companies. We are especially adept at working through the reimbursement maze and making sense of this complex and perplexing subject. Our ability to obtain favorable third-party coverage and payment for medical devices and therapeutic procedures is legendary, with a 100%   success rate of reversing unfavorable coding decisions.   Some of the many ways that we assist worldwide market leaders in healthcare include:



Coverage Strategy

Pre Product Launch

To support payer coverage for new technologies, including pharmaceuticals, medical devices, new technologies, durable medical equipment and supplies, GM Associates analyzes the reimbursement climate prior to product launch by:

  • identifying potential problem areas
  • determining acceptable pricing
  • identifying existing HCPCS and CPT codes
  • evaluating the need for new billing codes
  • conducting clinical trials to support favorable coverage policy
  • researching third party payer policies

Post Product Launch

Following introduction to the market, GM Associates completes these critical components of a successful coverage strategy:

  • verifying HCPCS and CPT codes
  • submitting for new billing codes
  • developing reimbursement guides
  • advocating with third party payers for coverage and payment
  • providing reimbursement hotline services for customers and sales force

HCPCS (Healthcare Common Procedural Coding System) Coding

If a new device, pharmaceutical, medical technology or piece of equipment does not fit under an existing coding descriptor, it is essential to obtain a new code for billing Medicare and other payers.   GM Associates has a reputation for successfully presenting compelling rationale to the National HCPCS Coding Panel resulting in new codes for our clients' technologies.


CPT (Current Procedural Terminology) Coding

A CPT code, which describes a procedure or service performed by physicians and other healthcare professionals, is essential to bill Medicare and other payers. GM Associates successfully develops comprehensive clinical vignettes, required by the American Medical Association (AMA), resulting in the assignment of appropriate CPT codes for our clients' technologies.



SADMERC ( Statistical Analysis Durable Medical Equipment
Regional Carrier )
Coding

The SADMERC is the Medicare contractor assigned to determine if durable medical equipment, medical devices, prosthetics, orthotics, and supplies fit into existing HCPCS codes which are required to bill Medicare and other payers.   GM Associates effectively substantiates coding verification requests to the SADMERC resulting in the assignment of appropriate HCPCS codes for our clients' products.
 

Reimbursement Guides

End users demand coding, coverage, and billing information. GM Associates develops user-friendly guides that include the critical elements providers need about reimbursement for a specific product or technology. These customized guides include billing instructions, code lists, forms to support prior authorization and claims filing and other critical information.



Payer Advocacy

Payer advocacy is essential to ensure reimbursement by Medicare and other payers.   GM Associates identifies coverage and payment policy for existing products, new technologies, and clinical procedures. Our relationships with key personnel in Medicare, Medicaid, managed care organizations, and private third-party payers support our efforts to obtain favorable coverage policy, appropriate payment, billing codes, and formulary acceptance.



Billing Support

GM Associates develops customized billing guides and standardized documentation tools designed to ensure consistency for fast payment. Our experts provide training on effective billing techniques, coding, fee tickets, and documentation of medical necessity to support coverage and reimbursement from a wide variety of third-party payers.


Claims Appeal

Inappropriate coding and unrecorded or under-documented data result in post-payment review and payment denial. GM Associates has been instrumental in the recovery of millions of dollars in unpaid and denied claims. We utilize medical records review, documentation assessment, and expert witness testimony to help our clients obtain favorable payment decisions for services, technologies, and supplies.



Hotlines

GM Associates offers customized reimbursement hotlines operated by experts who provide customers and sales representatives a wide range of information and assistance. Hotline users include hospitals, outpatient clinics, nursing facilities, physicians, home care agencies, sales representatives, and billing departments. Companies who provide hotline services through GM Associates have dramatically increased sales revenue. Our reimbursement hotlines provide:

  • correct codes and billing guidelines
  • prior authorization fulfillment
  • documentation samples
  • claims filing assistance
  • appeals for denied clients
  • monitoring and tracking claims and favorable reimbursement





Medicaid Formularies

For inclusion on approved Medicaid formulary lists, it is necessary to work with each state agency on an individual basis. GM Associates effectively submits supportive materials and other required documentation to obtain approval for our clients' pharmaceuticals, medical devices, durable medical equipment, supplies, and new technologies.