Go to Top

Case Studies

Client: Novel Diagnostic Developer

Case: “Problem Payers”

Situation: Diagnostic company with novel FDA approved technology has been incorporated in medical association guidelines. Diagnostic has been granted CLIA certification waiver and CPT code and pricing has been established with CMS.

Problem: Large national commercial payers are denying claims as new and investigational or paying allowable rates below physician practice profitability.

Goal: Achieve positive medical coverage policy and optimal reimbursement rates and from Payer.

Approach: Act as outsourced account executive team. Engage Medical Directors and Contracting Executives from the Metabolic Markets payer network to educate on the situation and problem. Diagnose specificic payer issue, and develop internal advocacy to push towards resolution

Outcome: Continuing to address payer medical policy issues, improved claims processing issues. Communicated coverage nuances to provider customers, enhancing client standing with providers.