Case Studies

Our healthcare company clients have ranged from start-ups to Fortune 500 international firms. We firmly believe reimbursement and payer strategy is an integral part of an overall growth strategy. Therefore, our work is often directly with CEO and CFO level management and we have experience preparing management for board meetings or presenting to the board ourselves. Our analysis can be utilized when expanding into new markets or launching new products and can be used to make decisions on new sales staff locations.

 

Our diligence work is often for private equity firms involving a leveraged buyout but sometimes entails growth capital, venture capital, distressed investments, and mezzanine capital. We also work with lenders on diligence projects and investment banks when bringing a company to market. In this case, we provide a landscape analysis involving reimbursement, compliance, and a claims review.

 

We do not sell research or contract with firms that invest or trade in public securities (e.g. hedge, mutual, or pension funds).

 

Here is a sampling of case studies for both our corporate consulting clients and diligence for private equity, lenders, and investment banks:

Corporate Consulting

Market Reimbursement Analysis and Payer Strategy for Growing Physical Therapy Practice

Review of Claims and Reimbursement rates for in-network and out-of-network PT treatment across different geographies for both commercial and government payers. Using qualitative and quantitative analysis, we built a payer strategy to approach payers and move from FFS to value based contracts.

Coding Strategy for Cardiac Medical Device

Analyzed healthcare reimbursement system as a whole, not just based on current coding and reimbursement for similar cardiac medical devices, and developed a coding reimbursement strategy. The coding strategy was developed for both Medicare and commercial insurers and took into consideration of future trends in healthcare.

Strategy to Market Access and Approach to Insurers and Employer Groups for Diagnostic Testing Company

Prepared dossier, created market access strategy for commercial insurers and employer groups, and advised client of future Medicare policy changes that are likely to affect the future reimbursement for diagnostics. The dossier was created to approach chief medical officers and other staff members at insurers. The creation of a market access strategy involved a qualitative and quantitative analysis that divided insurers and employers group into tiers. A timeline was developed to coordinate a successful approach to insurers and employers. The preparation work of approaching payers included development of web presence, marketing slide deck, and conference materials. A sales force plan was created based on our market access analysis.

Federal Policy Analysis for Large Biotech Manufacturer

Review and track all federal policy changes for client and discuss likely future changes on bi-weekly call. Analyze all reimbursement and policy that could  potentially affect company and discuss likely impact. Help assist with any strategy development to approach federal government staff.

Medicare Policy Analysis for Hospice Company

Create a current Medicare reimbursement landscape analysis and develop likely future policy changes to take place over the next 3-5 years. The future scenarios discussed likely impact to client and recommendations how to prepare a strategy to approach future reimbursement changes.

Strategy of FDA, CMS, and Commercial Payer Parallel Review for Medical Device Company

Creation of a coding and reimbursement landscape analysis that outlines the likely reimbursement scenarios for a product coming to market. Developed a payer strategy that entailed working together with the FDA, CMS, and commercial payers so that market access would be timed appropriately with FDA approval.

Payer Strategy and Contract Management for Growing Primary Care Practice

Control all client contracts with insurers and be a part of the negotiating process for new contracts. Develop a strategy to approach payers based on qualitative and quantitative analysis, which includes claims data, and research on payer policies and trends. Developed plan to move from FFS to value based contract arrangements with both commercial payers and the government, including assisting with enrollment with demonstration projects.

Commercial Payer Negotiations for a Behavioral Health Company

Develop a strategy to approach commercial payers to maintain current reimbursement payment structure and build a strategy to approach payers in securing care model as best approach to manage patient population within that insurer. Develop plan to partner with advocacy groups, academics, and the government to build a successful care model that is nationally accepted as a leader.

Orphan Drug Reimbursement Landscape Analysis among Commercial Insurers, Medicare, and Medicaid

Conducted interviews and surveys with commercial insurers, pharmaceutical benefit management (PBM) companies, former Medicare and Medicaid staff to produce the current reimbursement landscape for orphan drugs. This analysis showed the difference in how each payer viewed orphan drugs and the reimbursement and coverage for these products. The project highlighted the likely challenges ahead in reimbursement, products for diseases likely under the most scrutiny, and likely changes ahead in policy and reimbursement over the next 3-5 years.

Biosimilar Drug Policy and Regulatory Analysis for DC Pharmaceutical Policy Group

Review history and political dynamics of Hatch Waxman and the impact of generic drug policy and regulations since the law was enacted to the current state. Compare the Hatch Waxman analysis to the development of the a biosimilar pathway approved by law and proposed by FDA regulators. The analysis produced likely similarities and noted differences between Hatch Waxman and the biosimilar pathway but also described likely scenarios to emerge in the coming years via legislation or regulation.

Transaction Diligence

Traumatic Brain Injury /Intellectual and Developmental Disabilities

Analysis of selected state policies regarding “certificate of need”, home and community based waivers, and long term support and services options.  Current and future predictions of state budgets, legislation, and effect of any changes in state policies on waivers and plan amendments affecting enrollment of services offered. This analysis was combined with federal policies, legislation, and budgets that would have an effect on state policy.

Autism Services

Focused 100% on commercial payer reimbursement and coverage policies for autism services. The main part of the research was focused on applied behavioral analysis therapy and the recent trends and likely future changes among insurers. The analysis combined state and federal law impact on insurers along with stakeholder and advocacy group effect on future policy development.

Urgent Care

Focused 100% on commercial reimbursement and coverage for urgent care services. Evaluated current reimbursement environment for urgent care among commercial payers in a targeted region and assessed likely future impact based on potential future changes. The diligence also included a deep dive regarding a claims and chart analysis. This work entailed reviewing claims per compliance of state and federal laws, billing appropriately per the insurer contract (over-billing and under-billing analysis), and a review of the billing operations and process. We also provided recommendations to improve the billing process and a detailed assessment of claims remaining unpaid.

Medicare Advantage

Analysis of Medicare regulations and legislation for home risk assessments used by Medicare Advantage plans. This analysis included a review of the current environment and likely future changes that may impact utilization and payment for home risk assessments.

Home Infusion

Analysis consisted of reimbursement and coverage for home infusion in Medicaid, Medicare, and commercial payers in a selected group of states. A claims analysis was also performed to identify billing patterns and compliance with state and federal laws. Medical records of patients were reviewed to ensure proper payment was made per policies and contract of the payer.

Substance Abuse Services

Focused 100% on commercial payer analysis on reimbursement and coverage for substance abuse services within a particular region. The analysis covered recent trends in this space and care models that appeared to be more favorable with commercial insurers. Reimbursement trend analysis and comparison to other models were also part of the report.

Freestanding Emergency Departments

Focused on both commercial payers and state policy. Analysis included a combination of reimbursement trends and likely future changes among commercial payers and also state policy and legislative analysis for targeted states. The state analysis also evaluated budgets of various states and stakeholder support and opposition for these facilities.

Ambulance Services

Our report focused almost entirely on compliance and billing for ambulance services. This included a thorough review of the compliance manual, training for billing staff, and review of claims to assure compliance with state and federal laws and appropriateness of billing per the patient’s medical records and payer contract. Our project also included a detailed on-site visit with company management, the head of compliance, and billing staff. Medicare reimbursement analysis was remaining portion of the report.

Specialty Pharmacy

Our focus was entirely on compliance with state and federal laws. This also included an on-site compliance visit and meeting with head pharmacist, company management, and tour of the facility.

Delivery of Services to Homebound Seniors

Our report focused heavily on state and local policy. We thoroughly evaluated state and local budgets for these services at a selected group of states. This included the process for creating a budget for the services in each state and analysis how the process has changed over the years. State policymakers and legislative committee staff in each state were researched and our analysis included potential changes in the future. Lastly, federal policy and budgets to states for these services were also a part of our analysis.