As part of our commitment to providing the most advanced regenerative medicine products available, we also provide resources to assist with reimbursement inquiries.
Organogenesis currently provides information on coding, coverage, and reimbursement, in addition to other tools for our Advanced Wound Care products. Additional information is also available on the Centers for Medicare and Medicaid Services website.
The Reimbursement Hotline is committed to providing physician and facility providers with general information regarding coding and patient benefit verification results.
You can reach out to an Organogenesis representative today at 1-888-432-5232 (option #3) for answers to any questions regarding reimbursement.
Or write to us at reimbursement@organo.com.
While the provider is responsible for appropriate coding, billing and for handling and solving the related challenges, our goal is to make this process as easy as 1,2,3. We strive to make reimbursement for PuraPly® AM, PuraPly®, Affinity®, NuShield®, and Apligraf® consistent and reliable.
The Organogenesis Advanced Wound Care products have all three.
Coverage for the Organogenesis Advanced Wound Care products depends on each patient's particular medical insurance. However, the process to determine coverage is simple and straightforward.
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| Commercial Insurances |
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| No Health Insurance |
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Medicare contracts with regional insurance companies to serve as an administrative function, including handling claims. These contractors establish coverage, process claims, and make payments for a particular geographic area of the country.
These contractors were once known as fiscal intermediaries (FIs) and carriers. Now MACs have replaced FIs and carriers.
Individual contractors can establish and publish coverage in an LCD. LCDs establish coverage, or non-coverage, for products, procedures, and other medical interventions. LCDs typically include the following sections: indications, limitations, documentation requirements, and coding.
The Medicare payment rate for our Advanced Wound Care products is calculated based on Average Sales Price (ASP) and is paid per sq cm. The Medicare payment rates for our product codes are updated quarterly based on reported ASP and are not geographically adjusted.
Medicare instituted bundled payments in the hospital outpatient and ASC setting for skin substitutes in 2014. Our Advanced Wound Care products are assigned to the high-cost skin substitute product group. The bundle payment rate is updated annually and geographically adjusted.
Current Medicare rates are based on claims adjudicated two years prior. Therefore new product costs are not included in the prior claims on which current payments are based. In order to foster innovative medical devices, drugs, and biologicals, Medicare created pass-through payment to include these new innovative medical devices in the current Medicare rate. Medicare for a limited amount of time (typically 2-3 years) will reimburse on top of a facility fee, a "pass-through payment" for the medical device, drug, or biological. This helps a facility give its Medicare patients access to novel therapies without increasing the hospital's costs or overall spending.
The Medicare payment rates for procedures are updated annually and are geographically adjusted.
The geographical adjustments account for factors such as cost of living for different areas of
the country.
The geographical adjustments account for both CPT codes for physicians and APC
codes for Hospital Outpatient Departments.
Commercial insurers contract with each participating provider and model their contracted allowables on Medicare payment rates. Some providers have specific negotiated allowables. Commercial insurers determine the contracted allowable by region and by provider. Providers should check with their commercial insurer to determine their contracted allowable. Contracts with insurance companies are confidential, so it's the provider's responsibility to understand the fee schedule by insurance company by insurance plan.
Medicaid payment rates and covered provider types are determined by each state's Medicaid program. Some states may bundle payment for product and procedure, so it is always recommended to check with each state program for payment rates, coverage, and benefits. Some Medicaid patients may have a spenddown, which they will have to meet before Medicaid will pay for services. Organogenesis provides assistance to check the benefits through the BV/PA Program.
You can reach out to an Organogenesis representative today at 1-888-432-5232 (option #3) for answers to any questions regarding reimbursement.
Or write to us at reimbursement@organo.com.