Medicare Reimbursement Rates Increase For Advanced Biologically-Based Fistula Treatment

Hospitals nationwide will receive six percent higher reimbursement payments for outpatient repair of anal fistulas using Cook Medical’s Biodesign Fistula Plug, a device designed specifically to treat this painful and embarrassing disorder of the lower GI tract. According to new Medicare payment schedules effective January 1st, hospital outpatient surgery departments will receive approximately $2,200 per procedure, while freestanding ambulatory surgery centers will be paid about $1,300 on average1. The new fee levels come at an opportune time, as fistulas continue to affect tens of thousands of patients each year in North America alone.

The Centers for Medicare and Medicaid Services (CMS) regularly review charge data from health care providers to determine future facility reimbursement rates. New Medicare fee schedules, published annually, reflect CMS goal of establishing appropriate payment rates without creating disincentives that could deprive patients of effective treatment. The actual amount of facility reimbursement depends on a number of factors, including the provider and/or site of service (whether a physician, hospital, or ambulatory service, whether inpatient or outpatient) and the facilities’ geographic location. Unlike Medicare, commercial insurance plans do not have a consistent national payment methodology, and fee arrangements between these insurers and health care providers vary considerably.

Since Cook introduced the Biodesign Fistula Plug in 2005, health care providers have increasingly recognized the strong performance of biologic grafts for fistula repair. A fistula is an abnormal channel that develops between body organs or an organ and the skin, often in the intestinal tract. Anal fistulas can develop because of mechanical stress caused by Crohn’s disease, colitis, diverticulitis and other inflammatory bowel diseases.2 They leak fluid, interfere with bowel movements and cause discomfort during sitting and moving. Many can be repaired with a simple procedure called a fistulotomy, but approximately 30 percent of anal fistulas are considered complex and require alternative treatments less likely to prevent anal incontinence.

The Biodesign Fistula Plug is the first device designed and FDA cleared specifically for closing anal fistulas. Unlike other forms of treatment, the Biodesign Fistula Plug does not have a risk of sphincter muscle damage, a potential complication of fistulotomy that can cause incontinence. To further optimize procedural outcomes, Cook recently introduced the Biodesign Fistula Plug Set, a collection of accessory tools designed to help physicians achieve best outcomes in use of the Biodesign Fistula Plug. Available now, the Biodesign Fistula Plug Set includes the Biodesign Fistula Plug itself, brush, irrigation catheters, syringe and sutures.

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