The Importance of Patient Access and Market Access Programs for Innovators in Wound Care 

Introduction

The Symposium on Advanced Wound Care (SAWC) is a premier conference for the medical technology (MedTech) industry, bringing together industry leaders, researchers, and clinicians to discuss the latest innovations in wound care. For MedTech innovators and wound care professionals attending the SAWC Spring 2023, one critical consideration is patient access and market access programs for the advanced technologies these wound care patients need. These programs can play a crucial role in ensuring that innovative wound care treatments and products reach patients in need of critical care for their disease state. This white paper explores the importance of patient access and market access solutions and programs for MedTech innovators specializing in wound care.

Patient Access Solution Platforms

Patient access programs (PAPs) are designed to provide reimbursement support for innovative medical technologies so that patients in need of crucial care for their disease state can obtain and use healthcare services, information, and resources.  A PAP is a crucial aspect of the healthcare system, as it affects the quality and availability of care for patients.[1] Tailored specifically to the initiatives, goals, and nature of each individual client’s portfolio of products, PRIA Healthcare’s PAPs help MedTech, and life science innovators overcome common barriers in patient access solutions.  By advocating on behalf of patients, building utilization data, and ultimately achieving positive payer coverage decisions (achieving successful commercialization) for MedTech innovators, PRIA’s patient access professionals are poised to support the liberation of novel technologies, with the end goal in mind being to improve patient outcomes for those in need of specialized wound care. For MedTech pioneers attending the SAWC, patient access programs can be a critical tool for ensuring that innovative wound care treatment reaches patients in need – faster.

PRIA Healthcare’s PAPs Capabilities:

Equipped with a proprietary, salesforce-powered, HIPAA – compliant, real-time, and cloud-based portal, PRIA Healthcare can execute the following to ensure that your novel therapy is accessible to those that need it most, driving the commercial adoption of innovations in wound care.

1. Benefits Verification: The process of researching and identifying information such as confirmation of insurance active statuses, copayments, deductibles, and coinsurance with a patient’s primary and secondary insurance company, and coverage that may be applicable based on submitted coding and health history of the patient and the payer’s current medical policy.
2. Prior Authorization/PreDetermination: Approval from a health plan that may be required before a patient received care in order for the service/procedure/technology to be covered by insurance payers. The goal of prior authorizations and Predeterminations are to request medical necessity oversight from the payer before a procedure is performed to ensure the patient’s needs will be considered medically necessary under that payer’s current medical policies.
3. Pre-Service Appeals: The request to change a prior authorization or predetermination denial of coverage for a planned health care service or technology. The member’s rights in the member’s benefit plan govern this process. To submit a normal pre-service appeal request, PRIA Healthcare’s expert case management team addresses information in the pre-service denial letter and, because of their thorough follow-through and experience on the appeals process and payer needs, has established an 80% win rate (highest in the industry) for appeals.
4. Post-Service Appeals: PRIA’s professional case management team advocates on behalf of patients and providers that have undergone wound-care services which were denied by payers by providing verbal and written requests to overturn an adverse determination made by the payer for care or service already rendered. PRIA will help providers move through the appeal levels of redetermination, C2C, and internal reviews successfully.  Our experienced team of coders can also review denied claims to ensure the claims were billed appropriately per that payer’s guidelines.
5. External Reviews: A review of a plan’s decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the payer denies an appeal, an external review can be requested, and PRIA’s experts are able to perform external reviews on behalf of patients and providers, including ALJs (hearings performed by an Administrative Law Judge).

Market Access Programs

Market access Strategies are designed to help MedTech innovators navigate the complex healthcare market and achieve commercial success. For MedTech innovators attending the SAWC Spring 2023, market access programs are indispensable for ensuring that innovative wound care products reach the market and achieve commercial success. PRIA’s Reimbursement, Value Generation, and Market Access strategic team consists of highly experienced individuals that help innovators identify where their technology fits within the healthcare and payer ecosystem and will develop and execute a successful market access approach.

1. Regulatory Compliance: Market access programs can help MedTech innovators navigate the complex regulatory environment by ensuring that their products comply with FDA regulations and other regulatory agencies including those outside of the US. PRIA Healthcare has carefully curated industry-renowned expert partners in regulatory compliance, prepared to drive dynamic and successful compliance strategies to ensure adherence of compliance regulations set forth by the FDA. The team can also look at regulatory clinical evidentiary requirements for FDA clearance to ensure that the innovator’s clinical data will meet the payer’s level of evidence requirements and assist with clinical evidence-generation plans.
2. Reimbursement Strategy: PRIA Healthcare’s Reimbursement, Value Generation, and Market Access (RVMA) accomplished and credentialled professionals are subject matter experts in developing reimbursement strategies appropriate for innovations in wound care. PRIA’s experts in CMS, coding, coverage, and payment reliably consult with partners to develop a tailor-fit pricing strategy, coding constructs, and coverage pathways depending on where stakeholders will be utilizing that technology and where it fits within the market access paradigm. PRIA’s team has robust strategic service offerings that can help technologies in all stages of market commercialization and conducts integral steps in the market access strategy execution.
3. Market Landscape Assessment: Market access programs can help MedTech innovators analyze the competitive landscape and identify opportunities to gain a competitive advantage in comparison to innovators that may forego this critical assessment. PRIA Healthcare’s RVMA experts are able to intricately provide analysis of the wound care innovation landscape and furthermore support successful reimbursement strategy.

Conclusion

Patient access solution platforms and market access programs are critical for MedTech innovators attending the SAWC Spring 2023. These programs can help MedTech, Biotech, and life science innovators overcome barriers to access, navigate the complex healthcare market, and achieve commercial success. PRIA Healthcare’s Patient access programs will align with the innovator’s market access strategy to provide benefits verification, prior authorization, pre-and post-service appeals, as well as external reviews that can help patients access and use innovative advancements in wound care.

PRIA’s market access programs can help MedTech innovators navigate the complex regulatory environment, develop, and execute reimbursement strategies and gain a competitive advantage in the wound care innovation market.

By leveraging PRIA’s patient access and market access programs, MedTech innovators attending the SAWC Spring 2023 can ensure that their innovative wound care products reach patients who need them and achieve commercial success in the intricate labyrinth that is the US healthcare market.

[1] Reference

PRIA Healthcare is a full-spectrum reimbursement services firm based in Connecticut. Vital to the successful commercialization of over 100 medical devices since 2012, PRIA Healthcare is an industry-leading partner of innovators in MedTech and Life Science. PRIA’s renowned experts in reimbursement strategy and health care economics provide support to medical device companies by navigating often challenging and otherwise uncertain reimbursement pathways, determining the coding, coverage, and payment for market access and adoption of new technologies. Agnostic to specialty and poised to support the entire product journey of innovations in healthcare from concept through commercialization. 

Please visit www.priahealthcare.com to learn more about PRIA’s portfolio, including services such as market analysis, reimbursement strategy and planning, and patient access solutions.  

PRIA Healthcare – Accelerating healthcare innovation.