What's the reimbursement for the ZstatFlu test?

• ZymeTx has verification of reimbursement up to $50 (average = $37.50).
• In fee-for-service plans, reimbursement follows a "reasonable and customary" (R&C) model. R&C varies from state to state and payors can opt to pay from 75-90% of R&C.
• In the preferred-provider organization (PPO) model, reimbursement is a percentage off R&C (10-25% off R&C, or $37.50-$45).
• In the point-of-service (POS) model, reimbursement can be a percentage of R&C or it can be determined by other means. Some plans are quite arbitrary in their reimbursement; others have no set amount and default to a percentage of R&C in small volume cases.
• In the capitated model, there is no reimbursement but rather a fee paid for total care, making anything done for the patient an expense. The driver in this model is that the test will pay for itself in cost savings. (see Advantages for Physicians.
• Medicare pays just under $20. This is the first Medicare reimbursement that is less than cost. With Medicare patients, the goal is to provide quality health care while minimizing financial loss. Although you will not be making money on the ZstatFlu test, its value lies in the cost savings and increased quality of care it provides. This subject is addressed below and in the FAQ section.

To further complicate this issue, each doctor has multiple payors and multiple contracts with the same payor. So the exact reimbursement varies and will range widely within the same practice.

Click here for answers to some of the frequently asked questions (FAQ) regarding reimbursement.

1. Reduction of additional testing to rule out other illnesses. A definitive influenza diagnosis eliminates the need for more invasive and expensive diagnostic procedures (e.g., spinal taps to rule out sepsis in children).
2. Reduction of antibiotic usage. The antivirals amantadine and rimantadine are less expensive than antibiotics. Also, overuse of antibiotics contributes to the growing problem of antibiotic resistance.
3. Reduction in the number of complications. Early treatment can prevent complications in high-risk individuals. Every year, influenza-related complications are responsible for $4,100,000,000 in healthcare expenses.
4. Reduction of hospitalizations due to early diagnosis and treatment. Patients at high risk for complications can be treated with antivirals and warned to be on the lookout for signs and symptoms of potential complications.
5. Reduction in the spread of influenza. When one member of a specific group (be it a family or a nursing home) becomes infected, prophylactic treatment of the entire group may be warranted. This approach is termed "index case management" and is especially important for high-risk groups.
6. Increased office efficiency. Patients calling in with flu-like symptoms can be triaged by a nurse. The test can be administered by the nurse, and physician encounters can be decreased when influenza is diagnosed.
7. Increased patient satisfaction. Throat swabs are very patient friendly and quick to collect. Test results are known in ~20 minutes. Patients feels like something has been done to tell them why they are feeling badly. With a definitive influenza diagnosis, the physician can set expectations on when the patient will get better and families know better how to plan their lives around the illness.
8. Increased member satisfaction. Treatment for influenza, which relies on a definitive diagnosis, allows more employees to continue working or return to work sooner. Fewer work days are lost to influenza and its complications - a point greatly appreciated by employers and employees alike.