Advanced Therapy Reimbursement Advisory

The payer knows more about your contracts than you do. We change that.

HealthPulse Advisors brings bilateral payer-provider intelligence to CAR-T programs, rural health organizations, and healthcare investors navigating the most complex reimbursement environment in modern medicine.

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FY2026 CAR-T Per-Case Economics — Key Findings
CMS MS-DRG 018 Base Rate (FY2026)
CMS IPPS Final Rule FY2026 — +17% vs. prior year
$366K
Average Drug Acquisition Cost
Pulice & Schulman; manufacturer WAC data (5 products)
$530K
Total Cost of Care — Academic Programs
Di et al.; Ghobadi; Cliff et al.
$608K
Published per-case loss after outlier payments
Penn/JCO 2020; Leech et al. 2020; Avalere Health 2025
$63K–$304K
Most commercial payer contracts have not been updated to reflect the FY2026 rate change. That gap is recoverable in the current contract cycle.
17%
CMS CAR-T base rate increase for FY2026 — most commercial contracts have not adjusted
CMS IPPS Final Rule FY2026
68%
of CAR-T programs lack fully negotiated single case agreements before first infusion
UNMC ASH 2023; benchmark analysis
$2.5B
Managed care portfolio managed at UCHealth — bilateral payer-provider experience
UCHealth, 2020–2024
7.7%
Medicare Advantage prior authorization denial rate — 80.7% overturned on appeal
KFF Medicare Advantage Data, 2024
Capabilities

Where we work.

HealthPulse operates at the intersection of payer contract architecture and provider revenue — the specific layer where most reimbursement loss occurs and where bilateral intelligence creates the most recoverable value.

01

Advanced Therapy Reimbursement Architecture

Systematic analysis of CAR-T, TIL, and HSC transplant payer contract structures against FY2026 CMS baselines. Identifies outlier payment gaps, single case agreement deficiencies, and Revenue Code 891 billing opportunities. Delivers a written gap analysis with dollar-quantified recovery opportunities ranked by payer and contract.

Relevant for organizations navigating: New or scaling CAR-T programs — FY2026 commercial contract alignment — Unexpected per-case reimbursement losses — Pre-program launch contract design
02

Rural Medicaid Sustainability & RHTP Advisory

Payer contract benchmarking and reimbursement sustainability analysis for Critical Access Hospitals in Rural Health Transformation Program-funded states. Identifies the gap between RHTP investment and underlying payer contract performance — the structural risk that causes transformation programs to erode after year three.

Relevant for organizations navigating: RHTP-funded CAHs in Montana, Idaho, South Dakota, Pennsylvania, Kentucky — New CEOs in first 90 days — Post-MA exit commercial contract optimization
03

Healthcare Investor Reimbursement Intelligence

Pre-acquisition and post-close reimbursement intelligence reviews for private equity portfolio companies. Quantifies payer contract risk and recovery opportunity as a component of healthcare investment analysis — the layer that does not appear in standard financial due diligence but directly affects EBITDA margin.

Relevant for organizations navigating: Healthcare acquisitions — 100-day plan development — Portfolio company reimbursement optimization — Value creation planning
Research & Insights

The CAR-T Reimbursement Gap:
A 2026 Benchmark Analysis

Published April 2026

A three-part benchmark analysis documenting the structural failures in CAR-T reimbursement architecture. Based on 60+ primary sources including CMS IPPS data, OIG reports, KFF Medicare Advantage analysis, and peer-reviewed studies from the Journal of Clinical Oncology, The Oncologist, and Avalere Health.

Section 1 — The Per-Case Payment Gap. CMS MS-DRG 018 pays $366,000 for FY2026. Average drug acquisition cost is $530,000. Published per-case losses range from $63,000 to $304,000 even after outlier payments — losses driven by three structural failures that exist before the second case.

Section 2 — The Medicare Advantage Denial Problem. MA prior authorization denial data by insurer, health system exit trends, and CAR-T-specific access delay findings. 80.7% of MA denials are overturned on appeal — but only 11.5% are ever appealed.

Section 3 — The Contract Intelligence Gap. SCA prevalence data, Revenue Code 891 billing protocols, payer-by-payer coverage policy analysis across Cigna, Aetna, Anthem, UnitedHealthcare, and Humana, and the outcomes-based agreement landscape.

Read the full analysis on LinkedIn →

The complete benchmark report is available on request.
Contact rene@healthpulseadvisory.com

Key Benchmark Findings — FY2026
MS-DRG 018 Base Rate $366K
Avg Drug Acquisition Cost $530K
Total Case Cost (Academic) $608K
Per-Case Loss Range $63K–$304K
SCA Deficit Rate 68%
MA Denial Overturn Rate 80.7%
FY2026 CMS Rate Increase +17%
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Leadership

Built on bilateral intelligence.

Rene Castillo, Founder and Managing Principal, HealthPulse Advisors
$2.5B Managed Care Portfolio

Rene Castillo is the Founder and Managing Principal of HealthPulse Advisors LLC. The firm was built on a specific insight: the reimbursement gaps that cost hospitals $80,000–$200,000 per CAR-T case are structural features of payer contract design that payers understand — and that most hospital organizations lack the bilateral intelligence to address.

Most advisory firms approach reimbursement from the provider side only. HealthPulse was built with direct knowledge of how payers model CAR-T costs, structure coverage policies, and write the contract provisions that determine what they ultimately pay. That intelligence is not available through standard revenue cycle consulting.

Harvard Medical School
Relationship Development Manager, MAIDA Initiative
Led global partnership development for the Medical AI Data for All initiative at the Rajpurkar Lab. Built and managed strategic relationships with hospitals and health systems across multiple geographies on IRB, governance, and regulatory readiness. 2024–2025.
Harvard T.H. Chan School of Public Health
Associate Research Fellow
Health economics research focused on the economic forces shaping healthcare costs, digital health outcomes, and provider payment equity. 2023–2024.
UCHealth
Managed Care — $2.5B Portfolio
Bilateral payer-provider experience across CAR-T, TIL, HSC transplant, and solid organ programs. Structured single case agreements and outlier payment architecture from the payer side.
Veteran-Owned Small Business  ·  SAM.gov UEI: SUT9RT37ZJ83  ·  CAGE: 1ADM1  ·  SDVOSB Pending
Member: AHA  ·  HFMA  ·  NRHA
Contact

The conversation starts with one question.

Does the reimbursement gap exist in your program, and is it worth quantifying before the next contract cycle? A 20-minute consultation answers that question at no cost.

Email rene@healthpulseadvisory.com
Phone (614) 200-4270
Offices Columbus, OH  ·  Denver, CO
Engagements Fixed-fee. Defined deliverables. National.

Request a Consultation

All engagements begin with a 20-minute discovery conversation. No obligation. We will tell you directly whether HealthPulse can add value to your specific situation.

Advanced therapy reimbursement diagnostics
Rural Medicaid sustainability and RHTP advisory
Healthcare investor due diligence
Payer contract benchmarking and renegotiation strategy
Contact HealthPulse Advisors →