When you have a new device or procedure they want to do within your organization, do you have a specific team that is responsible for looking at payor policies to see if this is a covered service and what the reimbursement would be to ensure your covering cost?
Comments
Yes, we do. This type of team is commonly known as Value Analysis Team or Value Analysis Committee and should include members with expertise in materials/supplies, reimbursement, cost, and coding. Clinical leadership (including doctors and nurses) is also usual.
Be sure you hit upon all of these--
FDA/CMS/Insurance approvals
Medical Necessity, Appropriate Use Guidelines
Equipment costs- fixed and per procedure
Staff training
Reimbursement- DRG / APC / fee schedule
Prior authorization requirements
Expertise of physicians -- learning curve to minimize complications, Is patient #1 told the doctor has never done this on a human?
We did as well when I worked for a health system. Similar to what Andrew described, it was committee comprised of Revenue Integrity, coding/billing, clinical leadership, finance/reimbursement, and materials.
I attached a template we used to organize the payer coverage information.
Hope you find it helpful! Feel free to email me if you have any questions.
Erin Cutter
ecutter@integratedri.com