Pricing & Reimbursement

Monetizing health products in a regulated market

Getting paid in healthcare requires navigating a complex reimbursement landscape. Your pricing strategy must account for who pays, how they pay, and what evidence they need to justify payment.

Reimbursement Pathways

Pathway	How It Works	Best For
CPT codes	Established codes for defined services	RPM, telemedicine, coaching
Digital therapeutic codes	Emerging codes for DTx products	FDA-cleared digital therapeutics
B2B SaaS subscription	Per-month or per-member pricing	Health system tools
B2C subscription	Patient self-pay	Wellness, fitness, mental health
Employer/plan sponsorship	Paid by employer or insurer	Chronic care, wellness
Value-based arrangement	Payment tied to outcomes	Population health

B2B vs B2C Pricing Models

Aspect	B2B (Health systems)	B2C (Patients)
Buyer	Budget holder, procurement department	Individual patient
Price sensitivity	ROI-based	Cost-sensitive
Contract	Annual, multi-year contracts	Monthly subscription
Implementation	3-6 month procurement cycle	Immediate
Churn	Low (contract-based)	High
Revenue	Higher, predictable	Lower, variable

Digital Therapeutics Coding

Emerging reimbursement codes for digital health:

American Medical Association (AMA) : Digital health CPT codes for various digital health services
HCPCS codes: Level II codes for devices and supplies
CMS reimbursement: Medicare coverage decisions for digital health
Private payer coverage: Varies by payer, increasingly covering digital health

Pricing Strategy Considerations

Value-based pricing: Price proportional to value delivered (cost savings, outcome improvement)
Tiered pricing: Basic, premium, enterprise tiers
Per-member pricing: PMPM model aligns with health system budgets
Implementation fees: One-time setup and integration costs
Success fees: Bonuses for outcome achievement