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Case Studies

Reimbursement Assessment Case Study

A start-up medical device company wanted to launch a new device for treating congestive heart failure. The device has superior clinical and economic benefits over existing technology. However, procedurally it was very different than anything that has ever been on the market. After conducting an assessment of the reimbursement environment it was determined that the company needed to establish coverage with the payers with an acceptable payment rate, as well as new codes for physicians and hospitals to use to be able to bill for the procedure.

PRG was retained by the company to develop and execute the reimbursement strategy, including key meetings with the Centers of Medicare & Medicaid Services (CMS) and the private payers. Several months after the launch, coverage and payment had been secured with CMS Contractors and several of the major payers allowing for rapid market adoption and strong profitability for the company.

Health Economics Case Study

A medical device company was about to launch a new product that was not eligible to receive separate reimbursement because it was considered part of the primary procedure. However, the company felt that hospitals had the potential of saving thousands of dollars a year through the use of the device. To prove this assumption, the company hired PRG to conduct a cost-effectiveness study. The study was structured to determine how the use of the device would compare current costs of care when performing the primary procedure to future care costs using the new device. The clinical assumptions used were based on the clinical input of the physicians involved in the study as well as leading experts in the field.

After completion of the study, it was concluded that the cost savings to the institutions not only covered the price of the device but also garnered additional cost savings and revenue for the hospitals. Presentation of the findings from this study to hospitals resulted in immediate adoption of the device and it has since become the standard of care, even without additional reimbursement.