Coverage and Evidence

Coverage and payment issues in the health care industry are extremely complex for many health care organizations. EBG Advisors and our affiliates have decades of experience representing health care clients in third-party coverage, coding, and payment/reimbursement issues in federal and state-funded health programs.

At the federal level, we assist clients with a full spectrum of federal health program issues concerning Medicare, Medicaid, TriCare, and the Federal Employees Health Benefits Program. At the state level, we assist clients with state Medicaid and other state rate-setting matters, state payor systems, and other state programs, such as high-risk pools for the chronically ill.

EBG Advisors focuses on government program coverage, coding, and payment/reimbursement matters; qualification for participation in federal and state health programs; and the procurement of facility licenses and/or certificates of need. We are available to advise clients on the requirements for operating and delivering health services to governmental programs. We also assist clients in maintaining corporate compliance with these highly regulated health programs.

Medicare Parts C and D Payment Policy Analysis

EBG Advisors has specific data and analytic capabilities to provide clients with a broad range of Medicare Advantage and Part D payment advice. We understand how rates are calculated, how the bidding process works, and how risk adjustment and Star Ratings affect payment to health plans. We have provided clients with analytic support and policy arguments regarding Medicare Advantage rates, risk adjustment policies, overpayment compliance, and the calculation of Part D premiums.

We advise many clients on issues across Medicare Parts B and D. Specifically, with respect to inpatient drugs, we have advised clients on a range of distribution channel issues, including those involving group purchasing arrangements. We also advise on whether a new product could be separately billable, included in the hospital’s global payment, or approved for Medicare’s new technology add-on payments.