Medical device manufacturers overcome great obstacles to get their product engineered and to the market. Once these innovators reach this point, however, they face another hurdle: convincing providers that payers will pay for their medical devices.
As much as healthcare providers may want to offer a new, innovative medical device, the hassle involved in pursuing prior authorization for that device can prompt them to reject it in favor of treatments for which they don’t need authorization or can get quick authorization. With limited staff time, providers often default to older methods that may not even be as effective as the new medical device.
When a medical device manufacturer can offer prior authorization services, they help get cutting-edge therapies to patients in need.
One client, a midwestern manufacturer of a high-frequency chest wall oscillation (HFCWO) therapy device, wanted to handle their device’s prior authorizations necessary for their provider clients. By loosening mucus in the chest wall, this device provides symptom relief for people with bronchiectasis or impaired airway clearance. Those who suffer from conditions like cystic fibrosis and chronic obstructive pulmonary disease (COPD) use it to achieve significant symptom relief.
One Medical Device Requiring Approval From Many Payers in Many States
The medical device manufacturer was well aware that, for providers to win prior authorizations, they would need to research and contact many different payers, often in different states. In today’s short-staffed healthcare environment, staff were already juggling many tasks and struggled to research payer guidelines, state regulations, and then wait on hold for an hour to get answers.
Aware of their time and capacity limitations but dedicated to providing optimal care, providers agonized over these difficult decisions. Medical device manufacturers can help.
Advanced Medical Technology Associate (AdvaMed) Clears Manufacturers To Offer Prior Authorization Services
Healthcare providers are often surprised to learn that medical device manufacturers are permitted to handle prior authorizations for their provider clients.
In 2020, the Advanced Medical Technology Association revised its “Code of Ethics on Interactions with Health Care Professionals” to permit medical device companies to “facilitate the preparation and submission of requests for coverage determinations, payer pre-authorizations, and pre-certifications” for a company’s technology. They even stipulate that medical device manufacturers can help with appeals of denied claims.
A trade association, AdvaMed does not carry the force of law, but federal and state regulators like the Department of Health and Human Services Office of the Inspector General most often side with the AdvaMed code.
Handling Prior Authorizations In-House Was Not Working
The client was running the prior authorizations using an in-house team, but their denials rate was high and their backlog was growing. With increasing interest in their chest oscillation device, this medical device manufacturer was looking for a way to:
- accommodate prior authorizations for new providers
- take care of their prior authroization backlog
- decrease their prior authorization turnaround time
- decrease prior authorization backlog and denials
In addition, they wanted a partner that could scale with them. Offering prior authorization services would provide additional value for the client’s prospects and differentiate them from their competitors.
This client was growing in the midst of the COVID crisis when the healthcare staffing shortage was at its worst. Without qualified staff, they began to accrue a significant backlog.
Futher, constantly playing catch-up, they did not have the time to review the reasons behind their high denials rate. When denials occurred and the manufacturer and provider didn’t have the time to research the reason or submit an appeal, they just let the case drop and the client could not get their device. No one was happy with this outcome.
Infinx Selected to Submit and Track Prior Authorizations
This manufacturer evaluated several prior authorization solutions. After demonstrating our experience with medical device companies and ability to scale quickly, they selected us.
We got to work right away reviewing cases the client manually uploaded to our portal. For this client, it was very rare that any two cases went to the same payer in the same state. Batch processing was out of the question. For this reason, we had our specialists call each insurance plan directly, initiate the case and follow up on all approvals. Once we got the answers, we notified the client.
With implementation completed, the workflow rolled out smoothly this way:
- Physicians and staff entered orders into our portal.
- These orders moved to the intake specialist’s work queue, where they were reviewed for accuracy. Given just a single device, only a few sets of dedicated CPT codes are involved.
- After researching payer requirements, the specialists checked the prior authorization for patient demographic information, tests, and diagnostic documentation requested.
- With authorizations initiated, our solution performed frequent, automated status checks with payers. It delivered real-time determination.
- Should peer-to-peer review be required, specialists alerted the staff immediately.
We also managed their prior authorization appeal process, ensuring every appeal is submitted on time.
Reasons Behind Denials Revealed and Rectified
With access to these prior authorization cases, our specialists were able to analyze all reasons for denials and report back to the client. We categorized these reasons based on information we received:
|Sr No.||Denial Reason||No. of Cases||%|
|1||Not meet medical criteria/Not medically necessary||31||45%|
|2||Insufficient Clinical Criteria as per Payer Guidelines.||23||33%|
|3||Facility & Provider OON, member doesn’t have OON benefits||9||13%|
|4||Insufficient Clinical Data as per Payer Guidelines.||6||9%|
Having the reasons behind the denials helped the client pinpoint errors in processes as well as which providers or staff members needed guidance.
When insufficient clinical criteria or data triggered a denial, we requested any documentation needed from the client so we could reprocess the prior authorization quickly. We also handled all the call backs received from payers.
Prior Authorization Efficiency Increases Brand Value
After quickly clearing the client’s prior authorization backlog, we began to initiate new prior authorizations within eight hours of case upload. We aim to get the prior authorization turned around within 24 hours, although certain payers can cause delays.
With prior authorizations processing efficiently, the client can ensure providers schedule efficiently and to maximum capacity. This capability helped our manufacturing client demonstrate significant value to their clients and prospects.
Denials and Required Specialists Numbers Drop
Insights into denial triggers also brought significant value for this client.
Once a company pinpoints why denials are happening, process and people issues can be fixed. As the above chart reveals, this client had workflow gaps that led to frequent medical necessity denials. Because our specialists have concentrated exposure to medical necessity requirements, they are adept at establishing this important standard. They not only rectify the cases in front of them, but they also share their insights with providers and staff so medical necessity can be established for new cases on the first upload.
With our guidance, the client began to upload cases that would meet payer medical necessity and clinical requirements on the initial upload. As they improved at submitting accurately, their need for specialists on our end decreased, saving them labor costs.
The client also appreciates the quarterly business calls with their customer success manager. Their discussions of denials analysis, changes payers are making to guidelines, trends in the industry, and more help them plan for their expanding future.
Mapping Out a Lucrative Future
With an efficient prior authorization partner, this client can promise accurate, timely prior authorizations for an unlimited number of healthcare provider clients. They frequently express their satisfaction with our support, teamwork and overall insights. In fact, they are currently test driving an expansion into our eligibility and benefits solutions. That they award us a consistent 10/10 on the Net Promoter Score survey tells us their improvements are making a difference.
Interested in expediting medical device prior authorizations at your company with a high level of reliability? Request a demo of our prior authorization solution here.
Do prior authorization hassles stop your healthcare provider customers from offering cutting edge medical device therapies? Read how one manufacturer offered prior authorization services to providers to speed auths and cut denials for a critical medical device.