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