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Enabling Appropriate Medicare Patient Access

Medicare patient access doctor


Large biotech company


Novel cancer treatment

Client Business Challenge:

Limited understanding of Medicare coding and reimbursement process, timeline and strategy necessary to ensure timely granting of appropriate reimbursement codes to enable billing and payment.


IP developed Medicare coding strategy for novel cancer treatment, enabling provider/patient coverage and billing payment in hospital outpatient and physician office setting.

Project Timeline: 11 Phases
, 2½ Years
These examples are for illustrative purposes only. Timelines and results may vary depending on specific client needs and business situations.

— START! —

15 mo. to Launch

IP assisted with strategy development.

Assisted client’s brand, reimbursement and pricing teams with strategy development prior to FDA approval of new therapy.

12 mo. to Launch

IP facilitated meeting with CAG in CMS for client.

Immediately following NDA submission of new drug (12 months prior to approval), IP facilitated a formal meeting with the Coverage and Advisory Group (CAG) in CMS for client.

6 mo. to Launch

IP collaborated to assemble support for J & C code applications.

Collaborated with client’s internal medical team to assemble all necessary clinical support for J code and C code applications.

4 mo. to Launch

IP enlisted oncology thought-leader advocate.

IP engaged a prominent, oncology thought leader as a clinical advocate to advocate for client’s new cancer product at formal CMS meeting.

4 mo. to Launch

CMS Meeting

IP attended CMS meeting with clients team and oncology thought leader.

4 mo. to Launch

CMS relationship established.

CMS Coverage and Advisory Group (CAG) gained a positive impression of client’s new cancer treatment following the formal meeting. This also served to build a positive foundation for client’s corporate relationship with CMS.

3 mo. to Launch

IP submitted coding applications to CMS.

All coding applications were submitted prior to CMS deadlines.

2 mo. to Launch

Prepared for CMS meeting.

IP worked with clients brand, legal, medical and clinical teams to development CMS Briefing Book prior to CMS meeting.


FDA approval received!

Upon FDA approval of new therapy, IP facilitated submission of FDA approval letter to CMS.

5 mo. after Launch

C Code granted.

Client was granted a C code two quarters after FDA approval which enabled hospital outpatient reimbursement for the new cancer agent. Hospital sales revenue began to grow.

15 mo. after Launch

J Code granted.

Client was granted a J code in the following January after FDA approval which enabled community oncology clinic reimbursement for the new cancer agent. Physician office sales revenue began to grow substantially.

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