Reimbursement
Also known as: Insurance Coverage, CPT Codes, CMS Coverage
The mechanism by which healthcare providers are paid by insurers or government payors for using a medical product or service.
Full Definition
Reimbursement is a critical element of the H-BMC Authorities block and a major driver of economic buyer decisions. Without a reimbursement pathway, economic buyers in most healthcare settings have no mechanism to pay for a solution regardless of its clinical value. Reimbursement strategy involves identifying or establishing CPT codes, CMS coverage decisions, and private payor contracts. The reimbursement pathway is often the longest and most uncertain component of healthcare commercialization.
Example
A diagnostic test with strong clinical evidence cannot achieve commercial scale because CMS has not established a reimbursement code for its category. The company must either pursue a Category III CPT code, establish Medicare coverage through a local coverage determination, or target cash-pay markets while pursuing coverage.