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Evidence gap analysis

Strategic analysis of the sufficiency of evidence to obtain reimbursement and HTA approval in Europe and recommendations about evidence generation

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Reimbursement summary for angioplasty of arteries of lower extremities

This post presents an extract from our reimbursement analysis for angioplasty of arteries lower extremities using plain and drug-coated balloons (DCBs) for peripheral artery disease in England, France and Germany. Plain balloon angioplasty is reimbursement via DRG solely and DCBs are reimbursement via combination of DRG and add-on reimbursement.
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KBV and GKV-Spitzenverband agreed on the billing of the hybrid DRGs in Germany

On March 7, 2024, the National Association of Statutory Health Insurance Physicians (KBV) informed that it had reached an agreement with the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) regarding the billing of the hybrid DRGs. The agreement applies retroactively from January 1, 2024.

The agreement describes the billing procedure and which data must be transmitted. The billing agreement also stipulates that the hybrid DRG may only be billed for a doctor directly involved in the procedure, e.g., the surgeon or the anesthesiologist. The hybrid DRG tariff can only be calculated once. It covers all examinations and treatments, including material costs, carried out in the immediate context of the surgery. Follow-up care that may be necessary for one of the procedures is generally not covered by the hybrid DRG.

The Hybrid DRG regulation lists the surgical procedures reimbursed via the new hybrid DRGs. These are selected hernia procedures, removing ureteral stones, ovariectomies, arthrodesis of the toe joints, and the excision of a pilonidal sinus. According to the regulation, it is still unclear whether physicians have to use the hybrid DRG for these procedures or whether billing according to EBM is possible as an alternative. However, the GKV has already taken a clear position and declared that the sickness funds would not bill for interventions based on the EBM catalog if a hybrid DRG is available.

As a short-term transitional arrangement, necessary adjustments to the EBM catalog regarding the billability of pre- and postoperative EBM codes, as well as an exclusion from billing of affiliated medical services when billing a hybrid DRG for the procedure, are still being negotiated between the KBV and the GKV. A decision by the Evaluation Committee will follow as soon as the agreement is reached.

The full details in German can be found here.

This news is just one of about 300 market access news collected by our team in the premium subscription service Market Access Monitor every week from more than 80 organizations. Access our paid service to stay on top of all developments specifically for your products in Europe (reimbursement news) and globally (HTA news). Access is organized as an online Database and email alert formats. Contact us to get a free, three-month, no-obligation trial.