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 the company’s U.S based sales representatives. The strategic objective of this case study is to highlight that companies may want to consider selling their products based on how they are covered and reimbursed by the health insurance payers, in conjunction with how their products are sold based on their internal plans.

The company described in this case study launched into the US a novel telemedicine technology platform 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 and in the physician office.

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

Our Approach

For our company client we developed algorithms to research and query Medicare, Medicaid and U.S. private payer databases to identify the beachhead payer. This was done by prioritizing each of the three payer groups based on the most favorable telemedicine policies, reimbursement amounts and rules.

The results from our data analytics determined Medicaid as the beachhead payer. Since Medicaid is offered in all (50) US states we researched all (50) U.S. states Medicaid telemedicine coverage policies, reimbursement amounts and licensing, credentialing and billing rules and regulations. The outcome of this analysis was to build a large and interactive database that allowed us to categorize and query the (50) states into three categories relative to the company’s telemedicine platform and US business plans. The categories were, states with Medicaid telemedicine positive coverage polices, states with negative Medicaid telemedicine coverage policies and states with inconclusive Medicaid 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, licensing and credentialing is possible.

States with Medicaid positive or negative coverage policies where further stratified based on the degree of restrictive coverage policies, licensing, credentialing and billing rules, 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 US Midwestern 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 and other qualified healthcare provider reimbursement amounts 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.