The Neurology Reimbursement Landscape
The visit is undervalued. The drug is where the dollars — and the risk — now live.
Neurology's economics have split in two: cognitively intensive, time-heavy professional work that the fee schedule chronically underpays, and high-cost infusibles and injectables whose buy-and-bill margin is under sustained payer attack.
On one side sits the clinical core — long evaluation-and-management visits, cognitive-assessment coding, and the diagnostic engine of EMG/NCS, EEG, and evoked potentials, all pressured by conversion-factor erosion and repeated cuts to physician-administered testing. On the other sits a fast-growing therapeutics book: disease-modifying MS infusions, CGRP injectables for migraine, and complement and neuromuscular agents, frequently delivered under buy-and-bill economics where a few points of net margin decide the enterprise.
Payers are moving aggressively to reclaim that margin through white-bagging and specialty-pharmacy mandates, step therapy, and prior-authorization gates on neuro biologics — while the emerging anti-amyloid Alzheimer's class introduces entirely new infusion, PET/CSF diagnostic, and monitoring economics. The same patient panel can be worth dramatically different amounts depending on how the drug is sourced, the diagnostics are contracted, and the visit is coded — and that is precisely where Fulcrum works.
Illustrative composition. Replace with your confirmed figures before launch; reflects current CMS/MedPAC methodology and public payer data, 2024–2026.
