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Reimbursement ConsultingPublic
(Government) and Private Insurance in the US
Each year in the United States over 5 billion claims are filed for
insurance payment. The vast majority of individuals treated by
physicians or other qualified providers have some portion of their
medical expense covered by government or private insurance. In order to
process claims in a consistent and cost-effective manner, the government
developed a universal coding system that is made up of two primary
levels in the US.
- Current Procedural Terminology (CPT Codes) and ICD-9 Codes
- Level I Codes (Current Procedural Terminology)are medical services and procedures codes used by physicians
filing for payment for services rendered. The CPT Codes are
maintained and republished annually by the American Medical
Association. ICD-9 codes are used in conjunction with CPT-Codes .ICD-9 Codes are diagnostic codes used by the physician to indicate
treatment for a specific injury/disease. The CPT Code (services/treatment} must match the ICD-9 Code (specific
disease or injury) for payment to be approved. CMS (Central
Management Services) provides a strong consulting role with changes,
new codes, etc.
- Healthcare Common Procedural Coding System (HCPCS Codes)
- Level II Codes-HCPCS Codes (Healthcare Common Procedural
Coding System) are used by providers other than physicians to file for
payment of durable medical equipment, prosthetics, orthotics and
supplies (DMEPOS). Statistical Analysis Durable Medical Regional
Carriers (SADMERC) has primary responsibility for assigning codes
and maintaing the product classification list. SADMERC is under
contract by CMS (Central Medical Services) to manage this portion of
HCPCS. Over 4000 HCPCS Codes currently exists for Durable Medical
Equipment and Supplies. To file for HCPCS codes the product must
either have a 510k or a letter of exemption from the FDA.
- Needs for Insurance Codes in the US Market
- When marketing a product that qualifies for payment by Medicare, an
insurance
code must be obtained in order to qualify for payment. A significant
portion of
many of these products is Medicare or private insurance. Private
insurers
generally follow the lead of Medicare regarding codes used and payment
schedule. For these reasons, most providers won’t carry products where
the
reimbursement path is not clear. Let mdi help you pick the best strategy
for
maximizing your provider payment/coverage opportunities with the
appropriate
codes.
- Introducing Your Product to Private Insurers
- Once mdi has helped you obtain the appropriate insurance
codes, the next step in securing reimbursement is to introduce
your new product to private insurers. In the U.S., virtually all
private health insurance is now with managed care (HMOs and
PPOs). Unless these managed care payers elect to cover a new
medical device or procedure, reimbursement will be limited and
profitability can be significantly curtailed. Let mdi help you
introduce your new device or procedure to managed care. We can
assist you in negotiating contractual agreements with HMOs and
PPOs which assure a profitable level of reimbursement for your
product.
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