Payers

Imagine meeting with a reimbursement consultant with your breakthrough medical device, totally confident in its clinical superiority. Then comes the first question, and you falter, realising that brilliant technology and regulatory approval represent the opening act in your commercial theatre.

The best reimbursement consultants will start with uncomfortable questions that separate genuine market opportunities from expensive science projects. These conversations can feel like intellectual surgery, dissecting assumptions you've held sacred while exposing the vulnerabilities you never knew existed.

Understanding what a seasoned reimbursement consultant will ask, and preparing for your meeting with robust answers, can make all the difference between commercial success and costly delays.

I didn’t need to prepare a reimbursement strategy for my device. I know the industry inside out.

_{Unsuccessful applicant after ten years of trying}

The codes

The opening question will invariably centre on existing reimbursement pathways. A consultant worth their salt will immediately ask what existing reimbursement codes apply to your device's use case, and how confident you are in making that assessment. In the UK, your pathway to NHS reimbursement hinges on OPCS-4 procedure codes, whilst DRG classifications dominate across Europe. The consultant is testing whether you understand the fundamental infrastructure that governs medical payment.

Too many companies that have spent millions on R&D but never properly researched their coding pathway. They assume existing codes will accommodate their innovation, only to discover they need entirely new categories, a process that can take years.

_{Dr. Rachel Edwards, former NHS commissioning lead}

For breakthrough technologies, the coding challenge intensifies. Digital therapeutics, AI-enabled diagnostics, and combination devices often fall between traditional categories. Consultants will push you to articulate precisely how your innovation fits within existing frameworks.

Proof of value

Once your coding pathways are established, the conversation shifts to clinical evidence. This is where it’s critical to prove superior outcomes or cost savings, and how your device aligns with payer evidence requirements. Consultants understand that MHRA approval demonstrates safety and efficacy, but payers demand comparative effectiveness, economic impact, and real-world applicability. Your randomised controlled trial data may be pristine, but it needs to address the questions payers will ask of you.

The consultant will also assess your evidence gaps, such as where your data is weakest, what additional studies payers might demand, and your knowledge on real-world effectiveness versus controlled trial conditions.

Your pricing story

Pricing discussions reveal strategic thinking. Many MedTech companies approach pricing through cost-plus methodology, calculating manufacturing costs and then adding their margins. Experienced consultants will immediately recognise this amateur approach. Successful pricing strategies focus on value delivered, not costs incurred.

The questioning intensifies around price positioning. If you're priced above existing alternatives, what superior outcomes justify the premium, and have you considered NICE thresholds? If you're priced competitively, how will you maintain margins whilst demonstrating clear differentiation? If you're priced below competitors, why should payers believe your quality claims?

The payers

The core question will ask whether you’ll approach the NHS, private insurers, or specific health systems first (followed by your rationale). This question will show whether you understand the variability in your payer’s data. For example, the NHS has different specialities, regions, and commissioning groups that maintain distinct priorities and decision-making processes. Private insurers operate under different constraints than public systems. European markets each maintain unique assessment criteria and approval pathways.

Your supporters

Stakeholder engagement questions separate relationship-builders from technology-pushers. They will ask whether you’ve engaged with payers or Key Opinion Leaders to validate your reimbursement pathway, and about the feedback you’ve received. It will reveal whether you view reimbursement as a collaborative process or a transactional submission. Companies that have built relationships with clinical champions, payer medical directors, and patient advocacy groups demonstrate strategic maturity.

Plan for plan B?

One of the most revealing questions will address your contingency planning. You need to be able to talk about your Plan B if coverage is delayed or denied. This question separates those with wishful thinking and those with strategic planning. Successful companies maintain multiple reimbursement pathways, alternative pricing models, and adaptive go-to-market strategies. Your Plan B might involve your pursuit of different payer segments, how you plan to explore alternative pricing models like risk-sharing agreements, or how you’ve developed further clinical evidence to address coverage gaps. The sophistication of your contingency planning will reveal strategic depth and commercial maturity.

Value assessments need to be flexible enough to consider national or even regional distinctions in terms of funding and reimbursement pathways, including the role of payers and the diversity and nature of medical technologies.

_{MedTech Europe}

Waypoint checklist

A deep dive into your reimbursement strategy will prepare you for those tricky questions.

• Know what clinical evidence you have to prove superior outcomes or cost savings.
• Talk about how your price compares to other alternatives.
• Define which payers you’re targeting first, and why.
• Engage with payers or key opinion leaders to validate your reimbursement pathway.
• Plan your Plan B, should coverage be delayed.

Need help with your payment strategy?

These interrogations might seem daunting, but they're precisely why we can help with reimbursement readiness. Rather than facing these questions unprepared during crucial consultant meetings or payer presentations, we’ll help you develop compelling answers in advance.

We simulate real consultant conversations and identify any weak points in your reimbursement strategy. We help you research coding pathways, strengthen your clinical evidence story, develop pricing rationales, and build stakeholder engagement plans.

Expect to get clear action plans, stakeholder mapping templates, and evidence generation strategies aligned with payer requirements. Most importantly, you'll gain confidence to engage consultants and payers as strategic partners rather than intimidating gatekeepers.

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