The Road to Coverage
Insurance reimbursement concerns are important to consider when deciding whether or not the TIF procedure with the EsophyX® device is right for your patients or practice. Some private insurers may still consider the TIF procedure to be investigational for the management of GERD and may be hesitant to provide coverage because of this. However, published study results now confirm the efficacy of the TIF procedure with the EsophyX device. These trials, along with the new 2016 CPT code 43210, should help facilitate claims approval.
The CPT code is a reference code for hospitals allowing healthcare providers to more effectively receive reimbursement. As of January 1, 2016 the code is in effect and has been published in the AMA Professional Edition CPT® (Current Procedural Terminology) 2016 manual. Because the TIF procedure is minimally invasive, it can be performed in an inpatient, outpatient, or ambulatory surgical setting, expanding access to the procedure.
Navigating Reimbursement – Your Support System
EndoGastric Solutions (EGS) has a dedicated team of specialists available to help you and your GERD patients communicate the value of the TIF procedure to key decision makers at your third party payers. The goal of our team at EGS is to help your patients gain authorization and reimbursement. This process familiarizes payers with the TIF procedure and, over time, works to expand medical policy coverage.
EGS offers two levels of service:
- Consulting: EGS provides the tools and training that enable the patient to complete their own pre-determination
- Support: EGS works in partnership with the practice to execute pre-determinations and all levels of internal and external appeal
Support Services involve the following:
- Pre-Authorization including Pre-Determination: EGS offers a full-service TIF Authorization Assistance Program, which includes launching a pre-authorization and pre-determination request. This process ensures the payer reviews the patient’s medical necessity and individual health benefits prior to surgery.
- Internal Appeal: If a pre-authorization is denied, as quickly as possible, we help the patient through all levels of internal appeal and communicate with all stakeholders involved in the process. Our advocates will also assist with providing individualized appeal letters, proactive payer follow-up and support, and talking points for peer review.
- External Medical Review: EGS supports the patient through an external medical review by providing process guidance to the patient, talking points for review, and a medical literature archive.
At EGS, we are dedicated to advancing intervention for the treatment of GERD. Together, we can help educate payers on the limitations associated with open and laparoscopic surgery. We can assist payers to better understand the benefits of an incisionless approach to fundoplication. We stand ready to assist you and help your patients gain access to the most appropriate therapy for their lifestyle.
For authorization assistance, reach PRIA Healthcare at:
Phone: (860) 619-4133
Fax: (860) 215-8108