Market Trends in a Changing Reimbursement Landscape

This recording took place prior to the release of the OPPS Final Rules. For more information on those rules, click here.

Mr. Nelson is the VP Sales & Marketing for Swift Medical and Founder of the WoundCareFund & Below the Knee. 

• CMS WISeR Model: Voluntary program using AI to expedite prior authorizations; six pilot states testing tech-driven prepayment review. Providers using digital wound imaging and structured documentation tools may face fewer denials.
• Physician Fee Schedule & LCD Updates: Reduced reimbursement rates expected to tighten medical necessity thresholds (DFU/VLU) and emphasize evidence-based justification for cellular/tissue-based products (CTPs).
• Care-Setting Realignment: Economic pressure may shift large-wound care back to hospital-based centers, while mobile wound providers focus on smaller wounds amid industry consolidation and growth opportunities.

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text.
 
So, you know, we've got a lot of things in play. We've got the WISeR (model) being implemented in January. We've got the reduced physician fee schedule in January. We're waiting to hear if the OPPS is going to follow suit. And then we had the LCD that nobody seems to talk about anymore but might still be coming out. I'm assuming it is until we hear otherwise. If I look at the trends—greater prior authorization prepayments. So, we know WISeR is “voluntary,” meaning if you don't volunteer, you're going to face some scrutiny. You have the six states that are really looking at CMS now incorporating technology to try and speed up the prior authorizations and weed out waste, fraud, and abuse. I think we're probably going to be looking at potentially an expedited review process for those providers in those states that kind of played by those rules. So again, if I've got to fight fire with fire—CMS is going to be using AI in the WISeR process to expedite the review. So, are you as a provider now using digital AI tools to create the justification for the reasons you're requesting? If you've got a digital imaging process where you're capturing information, I think you're going to be better suited to then provide justification, right? They're looking for data and looking for lack of variability, I believe, right? So if I've got a system that provides consistently accurate measurements of wounds across different providers, I'm kind of not raising a red flag. If I've got data that builds why I'm doing what I'm doing, if using a digitized wound imaging system walks me through building a comprehensive chart simply by using the tool, I'm going to be in a better place to push through some of these new automated systems I would expect. It hasn't happened yet. So, a little crystal balling. 

Other trends, you know, with the reduced reimbursement rates, so a dramatic drop in the high end. You know, the high end was not the majority, but it certainly brings the average up, so it's kind of that mean median. I expect we're going to see some patient population shifting a little bit. You know, historically, patients with large wounds were not treated as often in a wound care center because they had capitated pricing, so it became difficult for them to kind of manage that and maintain a margin. And then coming out of COVID, all of a sudden, we have this mobile environment that allowed, you know, some creative reimbursement that really then made large wounds economically viable. So now you've got patients with large wounds being treated in a mobile environment and patients with small wounds kind of going into the wound care center. So not that it'll invert overnight, but I do think that this opens up wound care centers to kind of capture some of those large wounds that previously, it just, they ate them, right? It was a loss. And then the mobile providers are, you know, I would guess probably now going to be by default focusing in some of the smaller wounds. 

I think we're going to see at the end of the day, (that) mobile is not going away. Mobile wound providers are not going away. You know, some of the smaller, if I'm a distributor and I had, you know, three friends that were providers and, you know, we were kind of driving maybe the higher end of the ASP, those businesses may not survive, or it may not be in the position where it just makes sense, right? It's not juice and worth the squeeze for where they want to be.

So, I definitely think we're going to see some churn. But, you know, I'm speaking to multiple mobile provider groups, you know, every day that are looking at this as an opportunity. CAMPs is a portion of their practice, not the majority of their practice. And they know that as patient population shifts, some providers go out of business or decide not to remain in business, you know, they're making land grabs. They're growing their practices as a result of this shift. So that's another thing I think. And then, the new and revised LCDs, I'm assuming they will come to fruition until we're told otherwise. (It’s a) 50-50 guess. 

But, you know, I think that tightening indications, medical necessity thresholds, do I have DFU, do I have VLU coverage? I think that's going to continue to amplify the need for evidence. You know, we've got a lot of CAMPs in the market. We've got many that have good data, many that have some data, many that have no data. So I think, that's a good thing—I should at least have a clear barrier to entry, what is the minimum threshold? So I think that's going to continue to, as that's been in place. And I think that trend will continue of captured data. Not everybody's going to need 100 patient RCTs. Some do, some don't. That's more for the payer network grab. But just being able to have data beyond a five-patient case study that shows the effectiveness of the product. If you've got a different processing technology, if you've got a different, you know, core principle of where your CTP came from, you should be able to provide some consistent data that shows how you're equally as effective as other products and then certainly getting into the Medicare Advantage into the private pay network, you're going to have to have the data to get the coverage.