Project Description

Fortune 500 Company Applies Medicaid Coverage Policies for Telehealth Sales Planning

The Client’s Business Needs

This case study illustrates the use of payer and reimbursement data for decisions related to a company’s sales and marketing operations, specifically the location of its U.S based sales representatives. The strategic objective of this case study is we believe companies may want ro consider selling their products based on how they are covered and reimbursed by the Payers, and focus less on how their products are sold based on internal plans.

The company’s technology platform was comprised of an integrated camera and conferencing system capable of conducting real-time, simultaneous telemedicine sessions with multiple individuals located in different locations. The telemedicine platform integrates with major patient Electronic Medical Record (EMR) enterprises. The platform is also capable of real time sending, editing and sharing of a variety of formatted data between all the participants before, during and after the telemedicine session. The telemedicine platform has a small footprint and is portable, features ideally suited for use in the patient’s home.

The company’s business need was for us to help them determine where to locate their sales representatives in the U.S. based on telemedicine coverage policies, licensing and billing rules and reimbursement amounts.

Our Approach

For our client we developed algorithms to research and query Medicare, Medicaid and U.S. private payer databases so we identify and prioritize these three payer groups based on the most favorable telemedicine policies and rules and reimbursement amounts.

The results from our data analytics determined Medicaid is the beachhead payer and is where we focused our efforts from here on out.  We researched all (50) U.S. states Medicaid telemedicine coverage policies, rules and regulations and reimbursement amounts. The outcome of this analysis was for us to build a database that allowed us to categorize and query the (50) states into three categories relative to the company’s telemedicine platform. The categories were, states with Medicaid telemedicine polices with restrictions, states with negative coverage policies and states with inconclusive telemedicine coverage policies.

The U.S. states with inconclusive results where moved to the next research phase. This phase required us to conduct primary research to categorize the state’s Medicaid telemedicine policies, rules and reimbursement amounts.

States that do not cover and reimburse for telemedicine services where eliminated because healthcare provider reimbursement is not possible.

States with Medicaid coverage and reimbursement for telemedicine services where further stratified based on the degree of restrictive coverage policies, licensing and credentialing, the breath of services reimbursed, and the amount reimbursed to the healthcare providers for preforming telemedicine session.

The Results

Based on our stratification of the states with telemedicine policies, we recommended to our client to consider placing sales representatives in five Midwest states based on the following rationale.

1) Broad spectrum of covered telemedicine services is available.

2) Least number of restrictions for the available telemedicine services.

3) Physician reimbursement amounts, including other providers, were average to above average and had little historical fluctuations.

4) Good sized metropolitan areas serviced by major airports and highways. Automobile driving terrain is flat and time zone differences minimal.  This case study is intended to be an introduction to the use of Payer and reimbursement data to help solve business operational questions and strategically consider selling medical technologies based on how they are covered and reimbursed by the Payers and focus less on how the products are sold.

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