Reimbursement Impact of Obamaacare on New Tech

By MaryCorkins

For new technologies in healthcare, the process of addressing barriers to market adoption has remained largely unchanged over the last decade. At launch, manufacturers must be able to demonstration clinical endpoints and utility beyond the requirements of the FDA. They must also be prepared to support professional services training, the educational needs of all stakeholders, and the coverage, coding, and reimbursement needs of Providers and Insurers related to the new technology.

Beginning with implementation of the first phase of the Patient Protection and Affordable Care Act (a.k.a. Obamacare or PPACA) in September 2012, healthcare insurers began revamping their pre-service authorization processes. Today, these changes have been fully developed and incorporated into the Insurers’ reimbursement procedures. These changes have resulted in significant reduction of patient access to new technologies and reduced provider visibility in care guidelines decision-making.

Insurer Process Changes under Obamacare since September 2012:

  1. Many Insurers now provide only electronic Explanations of Benefit (EOB).
  2. Many Insurers now require provider “portal” (website) login to obtain status of Pre-authorization, Pre-certification, Pre-determination, and other pre-service requests.
  3. Many Insurers are no longer accepting pre-service requests for coverage/benefits, similar to CMS Medicare-like processes.
  4. Most Insurers do not permit nor accept pre-service provider-authored appeals, all pre-service appeals must be generated from the patient or guarantor.
  5. Virtually all Insurers have reduced benefits provided in clinical trial due to a poorly written law (Obamacare) opening the door to misinterpretation and misunderstanding and overall denial of benefits.

With increased Insurer permissiveness supported under Obamacare, manufacturers of new technologies must develop incremental support processes that address the increased burden for new technologies. These increased barriers have significantly extended the timelines, intensity of resource needs, and overall costs of new tech product launch. Manufacturers need to be aware of these new reimbursement barriers to adoption and address proactively, or be a victim of them and a failed launch.

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