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  1. An Evaluation of Omoda Medical Case Study




    Module 8: Case Study – Omada Health

    By Erin E. Sullivan, Research Director, PhD, and Jessica L. Alpert, Researcher. Center for Primary Care,

    Harvard Medical School, Boston, MA

    Link: https://mail.google.com/mail/u/3/#sent/FMfcgzGkXmhvmdcNXRpSdvkPLLbzTGSH?projector=1&messagePartId=0.1

    Case Study Questions:

    1. If you were James and Duffy, what are your next steps following CMS’s

    decision not to reimburse?

    1. What are the viable options or strategies for addressing CMS’s concerns

    regarding clinical efficacy?






Subject Nursing Pages 4 Style APA


Necessary Steps Following CMC`s Decision not to Reimburse

The decision by CMC not reimburse implies that both James and Duffy must take certain remedial measures to secure such reimbursements and to rectify any possible damage that could have accrued as a result of the same. CMC reasoned that their failure to reimburse was due to lack of compelling evidence concerning clinical efficacy of telehealth and DPP programs. There are three critical stages that are important when making a decision on whether or not to reimburse (Sutton and Wolf, 2020). These stages include coverage, coding and payment. Under coverage, James and Duffy must establish compelling clinical evidence that their devices are substantially able to improve clinical outcomes better than existing technologies. Secondly, the devices must have certain codes that help in the exchange of medical information between the payers and healthcare providers. When they establish the two, then they qualify for payment.

Strategies for addressing the concerns by CMC

James and Duffy must ensure they establish codes for their devices to make them adequate in terms of clinical efficacy.  The first strategy available for reimbursement is the need to undertake research to prove or establish medical benefit or additional value to the new technology over the existing ones in order to secure coverage (Sutton and Wolf, 2020). Secondly, the promoters would need to identify the codes for such devices. Codes can be in the form of identifying surgical procedures, medical and drugs (Sutton and Wolf, 2020). Also, it would be essential for the promoters to submit their findings after the clinical trials to the Center for Medicare and Medicaid Services to approve the same for reimbursement. Consequently, James and Duffy would need to follow the above strategies to address the concerns that CMC raised.



Sutton, J., & Wolf, R. (2020). Medicare reimbursement uncompensated care strategies. Management in Healthcare4(3), 274-283.


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