U.S. Reimbursement Exploration: Essential activities

Understanding Coding, Coverage and Payment options for your Medical Device is an essential activity to prepare the U.S. Market entry of Medical Technologies. We believe it is also critical at very early stages of product development.

MedNest offers a affordable “Reimbursement Exploration” program to educate companies on the U.S. Reimbursement and Payment Models and establish their optimized options for Reimbursement Coding, Payment and related product Pricing. Workflow Economic benefits will be discussed if relevant.

The program generally includes the following:

1. Audit the Company’s product and solutions, and existing pricing rationales

2. Deliver a personalized U.S. REIMBURSEMENT and PAYMENT consultation to address specific needs of each companies, with topics including

  • Present a tailored overview of the U.S. Healthcare Payer-Provider system (e.g.. what is relevant to the product at hand only)

  • Present and discuss the different insurance and payer models and segments, including HMO, PPO, POS…

  • Present and explain the MEDICARE and other federal programs

  • Discuss, if relevant, the emergence of ACOs

  • Discuss the fundamentals of reimbursement codes ( DRGs, PACs, ICD-10 Diag and Procedures, CPT, DME…)

  • Explain the coverage decision by insurance companies, and / or MEDICAIRE

  • Payment values, and how they vary from state, insurer, and federal program

  • About Economic outcomes research and trials

3. Research of most relevant codes applicable to the company‘s products

4. Research of payment values related to the selected codes (MEDICAIRE, and possibly other payers)

5. Work with Company to establish a pricing model based on reimbursement.

5. Preliminary exploration on additional economic benefits/outcomes (Workflow, Material, Labor..)

6. Preliminary recommendations on how to demonstrate/prove the additional economic benefits

7. Final report and proposed preliminary reimbursement, payment and economic value strategy.

  • Summary of most relevant reimbursement codes

  • Summary of payment values for such codes (how much $)

  • Preliminary product pricing model waterfall

  • About marketing reimbursement codes to end user

  • Recommendation on additional economic outcomes

  • Need (and preliminary recommendation if applicable) of economic studies/trials


Timing? A typical exploration project takes 2 months

Budgets? The typical budget of the exploration ranges from $5,000 to $10,000. Developing a comprehensive economic model / reimbursement plan can be scope after the exploration program