When Reimbursement Doesn’t Match MedTech Value
Nicole Coustier has over 20 years of experience in U.S. Reimbursement and Market Access and has helped early-stage MedTech achieve widespread reimbursement coverage in the U.S.
In the MedTech world, value is often defined by the innovation itself, its clinical impact, the problems it solves for patients, and the efficiencies it creates for providers. But in the U.S. reimbursement system, “value” takes on another meaning: the specific dollar amount a payer will actually pay for that innovation.
Sometimes, those two definitions align beautifully. Other times, the mechanics of payment policy have a way of bending your carefully crafted value story into something far smaller than you envisioned.
When You Can’t Get a Code at All
One of the first hurdles to securing payment for a new technology is getting a code, CPT, HCPCS, or otherwise, that allows providers to bill for it separately. Without a code, your innovation is usually treated as part of an existing payment for a broader service.
In some cases, the coding authority may decide there isn’t enough volume, precedent, or specialty society support to warrant a new code. That leaves you in a position where separate payment is off the table from the start. Even if you can demonstrate strong clinical benefit, without a mechanism to bill for the technology, payment will remain rolled into whatever service it’s part of today.
When You Get a Code… But It’s Bundled
The next frustration comes when you do secure a code only to discover that it doesn’t lead to separate payment because it’s bundled or packaged into a broader payment grouping.
Under systems like Medicare’s Outpatient Prospective Payment System, certain device and supply codes are designated as “packaged,” meaning they’re assumed to be part of the payment for the primary procedure. In these cases, the presence of a code doesn’t change the payment to the facility, so your customers don’t see additional revenue for using your technology. The effort to apply for and win that code may still have value for tracking utilization, but from a financial standpoint, nothing changes.
When You Get a Code… But There’s No National Payment Rate
Another curveball is getting a code assigned but finding there’s no national fee schedule amount attached to it. This often happens with new HCPCS Level II device codes or with certain CPT Category III codes. Without a set payment rate in the Medicare fee schedule, reimbursement becomes a matter of individual negotiation between providers and payers, or between providers and their local Medicare Administrative Contractor (MAC).
The result is a patchwork: some providers may get paid adequately, others not at all, and commercial payers may take a “wait and see” approach before setting their own rates. For customers, this uncertainty can be a deterrent to adoption, especially if they have to take on the administrative burden of appealing claims or justifying charges every time they use the technology.
In these situations, the presence of a code can still be valuable for tracking utilization and laying the groundwork for future rate-setting. But without a national payment amount, it’s not the financial green light many companies expect when they hear “Your code was approved.”
When You Get a Code and Separate Payment… But It’s Valued Too Low
Sometimes the process goes “right” on paper: you get a code, you get separate payment, and you expect that payment to reflect your technology’s cost and value. But then, the code is crosswalked to an existing code with a lower payment rate or valued in a way that undercuts your pricing assumptions.
This can happen when the coding or payment authority decides that your technology is “substantially similar” to another device or service, even if you see it as meaningfully different. Once that valuation is set, especially in Medicare, it can be hard to move, and commercial payers often follow Medicare’s lead. What looked like a payment win quickly becomes a ceiling that’s lower than you wanted.
Redefining “Winning” in Payment Policy
These scenarios can be frustrating because they challenge the way MedTech leaders think about progress. Getting a code isn’t always the same as getting paid. Getting paid isn’t always the same as getting paid enough. And sometimes, the smartest move is to avoid chasing a policy change that won’t yield meaningful financial improvement.
That’s why it’s so important to define what “winning” looks like before you dive into a coding or payment campaign. Is the goal to create a clear billing pathway for adoption? To secure meaningful incremental revenue for providers? To track utilization for future evidence generation? Being clear on the objective can help you decide whether the fight is worth it, and what to do next if the outcome falls short.
Playing the Long Game
Payment policy mechanics won’t always match your definition of value in the short term. But each of these unfortunate outcomes still offers opportunities to regroup. They may point to the need for additional evidence, a different procedural workflow, or a shift in the target site of service.
In the end, the ability to navigate these policy mechanics with patience and strategy is often what separates technologies that fade from those that eventually find their place (and their price!) in the market.
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