Frequently Asked Questions

If you have an oncology drug, you know that NCCN©  has become integral to payer policy decisions. However, many payers stipulate the level of evidence that is acceptable for coverage. For example, Arkansas Blue Cross and Blue shield states: “An off-label use identified by a compendium as medically accepted if the indication is Category 1 or 2A in the NCCN compendium.”
DKP tracks oncology policy in Medicare, Medicaid, and top commercial payers, facilitating our client’s awareness of coverage advantages or disadvantages pertaining to their products and their competitors’ products.

DK Pierce PayerScope™ staff provides:
• Expertise in the injectable payer policy environment
• Unique understanding of our clients and their competitive products
• Timely dissemination of information
• Ability to quickly search for and find pertinent, valuable information
• Customized services and reports
• Direct e-Alerts including analysis and implications of relevant policy updates
• Valuable resource to field reimbursement teams
• Time savings
• Focus on relationships with our clients and payers

Reimbursement implications are influencing by many variables, including:

• Formulation (e.g., oral, self-administered injection, physician-administered injection)
• Disease state (e.g., cancer, arthritis, congestive heart failure)
• Setting of care (e.g., hospital inpatient, hospital outpatient, physician office, retail pharmacy access, home care)
• Clinical trial phase

DKP has created a clinical development resource to help the clinical team understand what important reimbursement questions should be answered during the development process. Additionally, we provide comprehensive milestone reimbursement analyses. These analyses include qualitative market research, and are intent on assessing how the pipeline product’s planned strategic clinical development and commercialization direction will be affected by current and trending reimbursement mechanisms.

Having a complete understanding of codes is essential to the success of a new product or procedure. Inappropriate coding can cause delays in claims processing or lead to inappropriate payments and ultimately may limit patient access.

DKP can conduct a thorough coding analysis of current coding systems such as Healthcare Common Procedural Coding System (HCPCS) drug, and Current Procedural Terminology (CPT) drug administration codes. Additionally, we assess the application of International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes and outline the action items necessary to ensure successful coding of the product or procedure, including strategies to mitigate issues with miscellaneous coding.

 In the recent past a positive coverage policy was sufficient to ensure provider and patient access. With the advent of clinical pathways, both physicians and various pathway vendors are now managing which drugs get used on which patients. Several payers have adopted pathways as a way to control cost.  The DKP PayerScope™ monitoring team keeps a watchful eye on the evolution of clinical pathways and other utilization management trends and our consultants keep our monitoring clients informed via DKP e-Alerts™. 

For example, DKP recently reported that a study of lung cancer patients by US Oncology and Aetna shows 'on-pathway' treatments save 35% of costs.  To see the entire DKP e-Alert™, click here. 
 

There are a variety of sources, both free and paid that can provide basic information. For Medicare and Medicaid the CMS website is a great place to start.
General Medicare/Medicaid Information

• http://www.cms.hhs.gov/MedicareGenInfo/
• http://www.cms.hhs.gov/MedicaidGenInfo/

For Managed Care Basics there are a number of website available as well as industry associations such as AHIP, AMCP, and PCMA.

• http://www.nlm.nih.gov/medlineplus/managedcare.html
• http://www.aishealth.com/

In addition to our customized reimbursement research, analysis and training, we also now offer focused reports specifically designed to provide basic reimbursement knowledge that addresses common healthcare questions and issues faced by staff in biopharmaceutical clinical development, product marketing, reimbursement analysis, national account management, and field reimbursement management. Please click here  to visit DKP Marketplace and log in with your company email to view the complete list of available resources for sale.

Up until recently, physician administered drugs were strictly a medical benefit managed by the medical department, with few specific drug policies. With the proliferation of expensive biologics and orphan drugs, payers are more closely scrutinizing ways to control escalating cost in this sector. By applying pharmacy utilization management oversight and tools, many payers now managing physician administered drugs with specialized injectable formulary tiers subject to significant coinsurance.

DKP can provide an analysis of the trends affecting a particular disease state and provide specific recommendations to help your company understand the implications of these trends to your product.

 In the real estate market the colloquial response for the three most desirable home characteristics is “location, location, location”. For Medicare claims it is “documentation, documentation, documentation!"

New drugs are always described by not otherwise classified codes (NOC) so additional detail is required on claims as they will be manually reviewed. In general, in order to expedite the review as well as assure proper payment, all claims should include the new drug name, dosage, mode of administration, NDC number, and description in the appropriate field of the claim form (CMS 1500/UB-04).

CMS will convert from the ICD-9-CM system to the ICD-10-CM system on October 1, 2013. The new coding system would incorporate much greater specificity and clinical information, which results in:

• Improved ability to measure health care services
• Increased sensitivity when refining grouping and reimbursement methodologies
• Enhanced ability to conduct public health surveillance
• Decreased need to include supporting documentation with claims

The ICD-10 codes are more granular than the ICD-9 codes and the codes will likely change for products that are on the market before the implementation date of October 2013. DKP can highlight the new ICD-10 codes for a particular product and make recommendations for the transition to minimize errors related to the coding of products.