Pharma reimbursement is a big topic that frequently becomes a complicated process—even more so in the case of innovative, complex specialty therapies. Access and reimbursement plays a vital role in patients' lives and overall health outcomes, removing financial barriers so they can gain access to lifesaving medications.

Unlike retail drugs, specialty therapies are often cost-prohibitive and tend to be accompanied by complicated health insurance coverage challenges (e.g., elaborate prior authorizations, step therapies, and initial payment responsibilities for buy-and-bill products). When effective reimbursement pathways aren’t available, even groundbreaking medicines risk being out of reach for the patients who need them most. 

This guide explores how field reimbursement impacts overall market access, patient affordability, and prescription drug availability. It examines the key stakeholders and main steps in the process, as well as how biotech and pharmaceutical companies can best navigate reimbursement challenges to bridge the gap between these revolutionary treatments and the patients they intend to help. 

What Is Field Reimbursement in Market Access?

Field reimbursement refers to the support a professional offers healthcare providers (HCPs) and organizations (HCOs), payers, and patients as they secure coverage and payment for treatments, particularly for high-cost specialty therapies. Individuals or teams holding this role act as an intermediary across these various parties, using their expertise to guide the process and overcome all the logistical and administrative challenges of drug reimbursement. 

The primary goals of field reimbursement are to ensure:

• Patient access: Breaking down barriers to innovative treatments so they are available when and where they are needed
• Affordability: Minimizing out-of-pocket costs for patients, making life-changing therapies financially feasible for them to start and continue
• Payer approval: Securing coverage agreements with insurers or via government programs to facilitate access to treatment

When all three of these goals are accomplished, cutting-edge therapies can be accessed by the qualified patients who need them most (and may have waited years or decades for an approved treatment). When over 25% of rare disease patients wait seven years for a correct diagnosis, minimizing patients’ time to start remains a shared imperative across all stakeholders.

Understanding Key Stakeholders in the Reimbursement Process

Getting patients to start and stay on prescribed treatments requires several key players working closely together. Each one is important in ensuring treatments are accessible and affordable, and they all share the same goal of helping qualified patients start their therapies as quickly and easily as possible. 

Key stakeholders in the reimbursement process include:

• Payers: Insurance companies and government entities evaluate the drugs administered and cover treatment costs. They assess clinical data, drug pricing, and policy requirements to determine what and how much they’ll cover, directly affecting patient affordability and therapy accessibility.
• Healthcare providers: Doctors, nurses, and pharmacists advocate for appropriate treatments and handle prior authorizations (PAs), appeals, and the documentation required by payers. They often work closely with field reimbursement teams to resolve coverage issues and develop efficient drug purchasing strategies to help manage costs.
• Patients: As the ultimate beneficiaries, patients must contend with insurance approvals and out-of-pocket costs. Their financial and emotional well-being often hinges on a successful payer-provider collaboration.
• Biopharma companies: These organizations develop and deliver specialty medicines. They support HCPs and patients with information, resources, and reimbursement services and negotiate with payers to secure favorable coverage terms.

When operating effectively as intended, these stakeholders provide patients with timely and affordable access to prescription drugs and the support services they and their loved ones need. 

Understanding the Reimbursement Approval Process

The reimbursement process for specialty therapies can be broken down into the following steps:

1. Coverage determination: Payers decide if the medicine will be covered based on clinical evidence, cost-effectiveness, and medical necessity. Limited access to payer data can delay these decisions, so pharmaceutical companies should provide clear documentation and evidence of health outcomes to support coverage and hasten this process.
2. Coding and billing: Accurate coding (e.g., HCPCS, CPT, and NDC codes) is essential for claims submissions. Errors can lead to denials. 
3. Prior authorization: Many specialty medicines require payer approval before treatment begins, but inefficient communication and missing information can stall approvals. Nearly 90% of physicians surveyed by the American Medical Association report PAs create a high administrative burden, averaging two business days per week of HCP and staff time. 
4. Claims submission: Depending on the product or set-up, claims must be submitted to payers for reimbursement. Missing information in these claims can trigger delays. 
5. Appeals and resubmissions: Denied claims often need to be resubmitted with additional documentation. To avoid lengthy appeals processes that slow down patient access, organizations should employ centralized tracking in a purpose-built CRM to help coordinate initial prior authorization requests, renewals, and any resubmissions.

Each of these stages has its challenges. Fortunately, biopharma patient engagement solutions like Courier Health can alleviate or eliminate these issues, significantly improving efficiency and outcomes throughout reimbursement.

Strategies to Navigate Reimbursement in Market Access

The reimbursement process for specialty medicines is often long, arduous, and complicated. As a result, biopharma drug manufacturers must think strategically as they prepare to launch new treatments, negotiate drug prices, and execute innovative market access strategies. 

Involving cross-functional commercial teams early in the process and mapping each step of the treatment experience/patient journey can help them unlock successful market access that accounts for the holistic patient and provider needs. 

In addition, biopharma companies should follow these actionable tips.

Engage With Payers Early

It’s important to engage payers early in the process to understand their requirements and to begin building strong relationships. This starts during the drug development phase to address any potential concerns and get on the same page regarding coverage criteria. Sharing data on clinical outcomes, drug prices, and patient needs is helpful to support your case.

Being openly communicative with insurance companies and relevant government entities will help clarify expectations and promote collaboration, ultimately improving access and coverage for specialty therapies.

Utilize Patient Assistance Programs

Patient assistance programs (PAPs) help reduce healthcare costs and improve access to specialty medicines. They provide financial support of various kinds to patients, including co-pay assistance, free medications, and insurance navigation services. By making these lifesaving treatments more affordable and accessible, PAPs allow more patients to start and stay on therapies for rare and complex diseases.

Streamline Workflows

The pricing and reimbursement process involves many moving parts and is one component of a holistic pharma market access strategy. 

A CRM system like Courier Health, designed to power the biopharma patient experience, can help considerably in operationalizing an innovative strategy and approach. 

Connecting patient journey data, HCP and HCO contact management and communication, building and automating workflows, predictive analytics, and surfaced recommended actions help guarantee that nothing falls through the cracks. With everything in one place, field access and patient services teams can efficiently manage workflows, track patient journey progress, and promptly address diverse requirements to keep patients moving toward the next milestone. 

Leveraging CRM technology to automate prior authorization processes saves time and keeps things moving. Purpose-built biopharma patient engagement solutions like Courier Health reduce manual burden and errors and free up critical resources, allowing teams to focus on strategic initiatives that move the needle rather than tedious administrative tasks.

Future Trends in Reimbursement

The pharmaceutical industry isn’t immune to the impacts of technological advancements like artificial intelligence (AI) and automation. These innovations are causing leaders to re-evaluate existing systems and processes and redefine market access. Nowadays, AI-driven analytics increasingly help predict payer requirements, risk score patients, optimize pricing and the drug supply chain, and tackle areas of unmet need in new ways. 

At the same time, automation intelligence simplifies documentation, processing, and communication across the patient journey. For example, a CRM platform like Courier Health with built-in automation intelligence helps identify PA renewal deadlines and proactively surface issues that would jeopardize patient access to much-needed therapies.

Outside of tech advancements, value-based pricing models, which tie reimbursement to treatment outcomes, are becoming more popular, increasing the need for biopharma companies to provide evidence of treatment effectiveness. This trend corresponds to a growing emphasis on the health technology assessment (HTA), which evaluates a drug’s clinical and economic value to inform coverage decisions.

These trends will continue to impact market access stakeholders. Payers may demand more comprehensive data, providers will need support navigating new models, and biopharma companies must adapt and stay at the forefront by integrating technology and leveraging data to more efficiently and effectively meet changing demands.

Mastering Reimbursement in Market Access

Getting specialty treatments into the hands of the patients who need them requires a thorough understanding of market access and reimbursement. Biopharma companies that master this can improve the affordability, access, and adherence of their drugs for patients. 

As specialty medicine spending continues to rise, so far totaling $400B, implementing a successful market access strategy and specialized internal field reimbursement team is a must. Courier Health’s easy-to-use CRM gives field reimbursement teams everything they need to succeed—centralized data, automated workflows, and proactive insights to make more informed, data-driven decisions. The platform surfaces recommended action items, allowing users to focus on high-priority interactions and drive more impactful results.

To discuss unlocking your field reimbursement team’s productivity and accelerating patient access to treatment, reach out today.