Orthopedists are reporting a rise in demand for knee viscosupplementation, also known as hyaluronic acid knee injections or knee gel. With the over-65 population in the United States set to double by 2060, the need for this therapy should increase for several decades.
In fact, in just the next five years, market forecasters predict that the viscosupplementation market size will grow by 9.45% per year, rising from 4.52 billion in 2021 to 7.08 billion in 2026.
Is Prior Authorization Required Or Not?
While rising demand promises to keep osteopaths paying the bills, increasing prior authorization requirements makes getting procedures booked more of a hassle. The wide variety of payers, payer benefits, and payment policies mean claims specialists must review each case individually.
Some private payers follow CMS policies, while others have more or less restrictive benefits than those mandated by Medicare and Medicaid.
Every year, CMS requires prior authorization for new service categories. While it doesn’t currently require approval for viscosupplementation, given the new services it adds to its prior auth list every year, providers never know when it could be. Hyaluronan acid therapies for knees osteoarthritis are covered as long as they meet the LCD criteria.
Bottom line is that some payers require prior authorization for viscosupplementation and some do not. Providers have been pushing back on these new requirements, citing, among other issues, a lack of guidelines through which providers would obtain prior authorization.
The Fastest Way To Determine Whether Prior Authorization Is Necessary
For those payers that do require prior authorization, typically when providers use viscosupplementation for its FDA-approved indication and follow all payer guidelines, payers grant prior authorization.
Payers regard appropriate candidates for viscosupplementation as those with knee osteoarthritis who have not improved with other non-surgical treatments like analgesics or anti-inflammatory drugs (NSAIDs.). They accept preparations of hyaluronic acid-based polymers approved by the U.S. Food and Drug Administration (FDA). These include formulations like GENVISC® 850 and Hyalgan®.
The first step is for the provider to determine whether prior authorization is even required. The two fastest ways to complete this task are to depend on your prior authorization software or — absent this tool — the manufacturer of the treatment.
With a multi-dimensional prior authorization software solution, each patient’s prior authorization needs are assessed in real-time. An AI-powered solution will provide an answer about a prior authorization requirement within 30 minutes. Its constantly-updated database of hundreds of payers (including CMS of course) returns the most current requirements.
Given that the Medical Group Management Association (MGMA) estimates that 42% of denials are directly attributable to missing or unapproved prior authorizations, accurate information about prior authorization is critical. The faster this answer is received, the sooner the orthopedist can schedule care and relieve patient pain.
Absent modern technology, the front office can contact the payer or the hyaluronic acid therapy’s manufacturer. Manufacturers track prior authorization requirements for hundreds of payers, particularly in regards to their specific product.
Winning Prior Authorization For Viscosupplementation
Payers put preauthorization requirements into place to ensure the treatment is medically necessary, appropriate, and cost-effective. Many recommend or even require a preferred brand of hyaluronic acid injections and deliver only through their specialty pharmacy. By knowing the preferred brand(s) upfront, you potentially prevent prior authorization denials. You may even want to keep these brands in stock if many of your patients utilize a certain insurance plan.
For example, BCBS (FEP) Federal Employee Program has a “HYALURONIC ACID DERIVATIVES” policy that outlines their policy and preferred brands used through their specialty pharmacy.
Given a payer does require prior authorization for viscosupplementation, careful submission helps ensure quick approval and prompt patient care. Use these tips to submit your prior auth correctly the first time.
Each payer requiring a pre-authorization has a unique workflow. Never assume that a system you have developed will work for multiple payers. The only way to get a clear picture of a payer workflow is to call them or visit their website. Variations include:
- Filling an electronic form
- Filling a hard copy form and emailing or faxing it along with all clinicals
- Phoning the payer
- Using the payer portal
Always go along with the payer’s preferred method.
Meet The Coming Surge In Demand For Viscosupplementation With AI-powered Technology Leveraged By Specialists
An aging, osteoarthritis-prone population is just one factor fueling the surge in viscosupplementation demand. Today’s patients are also more aware of hyaluronic acid knee injections and they have a preference for minimally invasive procedures over surgical ones. Getting prior authorizations helps ensure orthopedists capture the revenue this surge promises with as little hassle as possible.
Adding AI-powered patient access solutions automates minimally invasive orthopedic procedures from the point of insurance verification and patient pay estimation through prior authorizations and insurance discovery.
Request a demo to see how our solutions ease the prior authorization workflows to ensure your visco claim is preserved to get reimbursed.
