Hospitals and health systems are facing a growing volume of claim denials, with private plan prior authorization issues driving the recent increase, according to a new report from the American Hospital Association (AHA).

For the report, AHA surveyed more than 200 hospitals and health systems in 2019 to understand the impacts utilization management practices employed by commercial health plans had on patients and providers. The group also interviewed several hundred hospital and health system executives.

The survey found that 89 percent of hospital and health system respondents have experienced an increase in claim denials over the past three years, and 51 percent of all respondents described the increase as “significant.”Hospitals and health systems are facing a growing volume of claim denials, with private plan prior authorization issues driving the recent increase, according to a new report from the American Hospital Association (AHA).

For the report, AHA surveyed more than 200 hospitals and health systems in 2019 to understand the impacts utilization management practices employed by commercial health plans had on patients and providers. The group also interviewed several hundred hospital and health system executives.

The survey found that 89 percent of hospital and health system respondents have experienced an increase in claim denials over the past three years, and 51 percent of all respondents described the increase as “significant.”

Commercial health plans denied claims several different ways, including post-payment audit denials, partial or line-item denials, and downcoding. However, survey respondents highlighted claim denials and reimbursement delays stemming from prior authorizations.

The report stated that failure to obtain a prior authorization was one of the most common reasons for a claim denial from a commercial health plan. In some instances, respondents even reported plans denying claims even though providers could not wait for a plan’s response to a prior authorization request because treatment had already begun or a patient’s condition changed during the approved procedure.

Respondents also frequently cited instances of downcoding in which health plans reclassify inpatient claims to observation status, then deny the claims since providers did not request a prior authorization for the observation stay.

These claim denials are only adding to the burden hospitals and health systems face with prior authorizations, AHA stated.

Hospitals are expending significant resources to address prior authorizations, including different submission processes by health plan, changes in prior authorization policies midway through a contract period, and unreasonable or unrelated requests for additional documentation.

One 17-hospital system told the AHA that it spends $11 million annually on complying with health plan prior authorization requests, while a single 355-bed psychiatric facility reported needing 24 full-time staff to deal with the authorizations.

Overall, physicians reported that their offices spend an average of two business days a week managing prior authorization requests, and 89 percent rated the burden of prior authorizations as high or extremely high.

The findings underscore the need for greater oversight of private plan prior authorizations, including submission standardization, the AHA stated in the report.

The hospital group urged federal agencies including CMS and state insurance commissioners to standardize the format for communicating services subject to prior authorizations, the format of prior authorization requests and responses, the timelines for responses (i.e., 72 hours for scheduled, non-urgent care and 24 hours for urgent services), and the appeals process.

Additionally, the group called for health plans to respond to prior authorizations 27/7 and communicate denials fully and completely in writing, not just a verbal response.

But standardizing the prior authorization process and implementing other recommended reforms, like setting thresholds for appropriate levels of prior authorizations and penalizing plans for inappropriate denials, may require states and federal agencies to acquire additional authority, AHA stated.

The group advised policymakers to ensure federal law “not unduly restrict regulators’ abilities to ensure access to care and coverage for patients and fair reimbursement for providers,” the hospital group said.

The recommendations would also be key to helping hospitals and health systems fight the ongoing COVID-19 pandemic.

Although patient data security and privacy anxieties remain today, federal agencies and healthcare organizations faced a separate set of fears at the turn of the century, when health technology was first being integrated into care.

“There were definitely some fears,” Jay Nakashima, executive director of eHealth Exchange, said in an interview with EHRIntelligence. “First, there was the fear of healthcare data being broadly breached. Then there was the fear of some sort of an entity out of Washington, DC that maintained a central location housing all patient health information.”

It was out of those fears the Office of the National Coordinator for Health IT (ONC) and the Nationwide Health Information Network (NHIN) conceived of the eHealth Exchange in 2006 to securely exchange patient health data across the country.

“A federal network means each healthcare organization needed to create and maintain a pipeline to other healthcare organizations within the eHealth Exchange that it wanted to establish a patient data exchange,” he explained.

By 2009, eHealth Exchange first exchanged data between the Veterans Health Administration (VHA) and Kaiser Permanente. Within two more years, the network added 23 participants and by 2012, The Sequoia Project took the reins and fully supported the eHealth Exchange.

Now, the HIE connects to 75 percent of all US hospitals, over 60 regional or state HIEs, and four government agencies. It also connects 120 million patients across the country.

And most recently, eHealth Exchange can boast progress with its new gateway technology that simplifies connectivity for participants through a single streamlined connection.

“For example, Mayo Clinic has a patient that goes to Stanford in California because they are on vacation or working in the area,” Nakashima explained. “Our job is to create one to five or even 10 direct connections from Mayo Clinic to Stanford Health Care.”

READ MORE: eHealth Exchange Inks First Health Information Exchange Vendor

If a health organization creates less than 10 connections, it will not be burdensome or unmanageable for the HIE. However, if a health organization starts to generate hundreds of connections between two health systems, it can become onerous for the HIE and its participants.

“The eHealth Exchange implemented a centralized technology, called gateway technology,” he continued. “It’s a single on-ramp or a single connection to the country. Our providers and other healthcare organizations can create one connection to the eHealth Exchange. Then we route their transactions to providers all across the country so they do not have to have a high number of connections.”

eHealth Exchange exchanged roughly 550 million clinical documents using this new structure, which is up almost 300 million transactions from the old format dating about a year and a half ago.

“Data is flowing much more frequently and our customers aren’t having to spend as much money on creating and maintaining all of those point-to-point connections,” Nakashima said. “This means they are able to free up significant health IT resources to work on more valuable tasks.”

Furthermore, the new structure helps health organizations expand their national footprint and implement innovative capabilities, such as real-time content quality validation and a national record locator service.

The new approach also helps organizations prepare for regulatory changes, including the ONC interoperability rule and the Trust Exchange Framework and Common Agreement (TEFCA).

Looking forward to 2021, Nakashima said he expects to see more “data pushing,” rather than “data pulling” from health organizations. This is a more proactive approach to health information exchange, Nakashima explained.

When a patient arrives for her afternoon appointment, her data will already be available at that exact time and place, rather than having to pull the data when the patient arrives at the appointment.

Pulling patient data at the last moment could result in mismatched patient data and potential patient safety issues.

“The vast majority of our participants query every night,” Nakashima said. “An organization will say they have over 100 surgeries and 400 appointments the next day and the system will automatically query the night before, or a couple of hours before an appointment or a surgery, to pull that information and have it available in the EHR system for the clinician.”

Furthermore, eHealth Exchange participants can also set up push notifications to public health agencies across their respective state and county, and even across the country.

“Most participants have their EHR configured to automatically report when, for example, a patient tests positive for Hepatitis B, to automatically push a report to the county and state public health agencies, and then potentially the [Centers for Disease Control and Prevention] CDC.” Nakashima expects patient data exchange to continue to develop and improve in 2021 and beyond.

Post-acute electronic health record (EHR) company PointClickCare Technologies plans to acquire Collective Medical to expand its reach into care coordination across the acute, ambulatory and post-acute markets.

PointClickCare is a cloud-based software provider for the long-term post-acute care and senior living provider markets, and its EHR is used in 70% of U.S. skilled nursing facilities, according to the company.Collective Medical provides a network-enabled platform for real-time cross-continuum care coordination.

With the acquisition of Collective Medical, PointClickCare will solidify its position as a high-growth, cloud-based healthcare software leader, serving a large, diversified customer base of 21,000 providers across the acute, ambulatory, post-acute and payer spectrum, the company said in a press release.

Through the acquisition, PointClickCare and Collective Medical will provide diverse care teams across the continuum of acute, ambulatory and post-acute care with point-of-care access to real-time patient insights at any stage of a patient’s healthcare journey, enabling better decision-making and improved clinical outcomes at lower cost.

The acquisition is subject to receiving regulatory approvals and other customary closing conditions and is expected to be completed by the end of December.

“The healthcare ecosystem is a mix of disconnected providers, systems, plans, processes, and data. Healthcare costs and risk are on the rise, while patient care and provider-to-provider coordination are inconsistent. Our mission is to improve the lives of seniors, and we believe the best way to meaningfully advance this goal is by connecting disparate points of care,” said Mike Wessinger, founder and CEO of PointClickCare Technologies, in a statement.

“Collective Medical offers the right fit of people and technology and together we will initiate a new era of data-enriched collaboration across the continuum that radically transforms how data and people are empowered to liberate health,” he said.

PointClickCare also has expanded its reach into the long-term post-acute care market with the acquisition of QuickMAR, an electronic medication administration platform, in 2019.

PointClickCare supports a network of more than 21,000 skilled nursing facilities, senior living communities and home health agencies. In the U.S., 97% of all hospitals discharge patients to skilled nursing facilities using PointClickCare. Collective Medical’s platform connects more than 1,300 hospitals, thousands of ambulatory practices and long-term post-acute care providers, as well as accountable care organizations and every national health plan in the country, across a 39-state network.

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These providers come together via the Collective platform to support patients suffering from a variety of complex conditions, including substance use disorder, mental and behavioral health issues, and other care needs requiring multiple interventions and transitions across disparate care settings. The combination of PointClickCare and Collective Medical will enable care to be more seamlessly delivered for the most complex (high-cost, high-needs) patients, including the rapidly growing aging population, the companies said.

“There is near-perfect alignment between Collective Medical and PointClickCare given our shared values and mission to support vulnerable populations,” says Chris Klomp, CEO of Collective Medical.

As the shift to value-based care fuels growing market demand for intelligence and collaboration tools, PointClickCare will be better positioned to provide a fully integrated set of real-time care coordination tools across the entire continuum of care, powered by the largest network of its kind in the U.S.

The acquisition will follow a partnership, created between the companies in August 2019, which streamlined the integration of Collective Medical’s solution for care transitions with PointClickCare’s leading cloud-based software platform.

Cancer is a very serious situation, which is why many people want to know what they should do once they’ve been diagnosed with this deadly disease. Cancer can have life-changing effects on a person’s life and can cause anxiety and depression. Roles at school, work, and in the family are also affected negatively because of cancer.

Fortunately, with the advent of technology, there are now many ways on how you can detect cancer early on, increasing your chances of survival. Cancer is a dreaded disease but there are machines that can help medical professionals examine your body and assess if cancer cells are growing and multiplying inside. These techs can even identify whether your cancer cells are aggressive and which parts of the body are they damaging.

Once you’re diagnosed with cancer, it’s best if you take on the steps listed below so you can easily manage symptoms and battle cancer:

Consult With A Doctor

As mentioned, cancer is a dreaded disease and you need a medical professional to explain what could happen to your body and what symptoms would you possibly experience after the diagnosis. Consulting with a medical professional is essential because it allows you to look at the bigger picture of cancer and prepare your mind and body for what’ll happen next. The more informed you are about your condition, the better your chances will be of getting a proper treatment plan.

Moreover, a medical professional can also provide possible treatment options for the kind of cancer you have. Early cancer diagnoses usually mean more treatment options for cancer patients. However, when choosing a cancer treatment, make sure to ask your doctor about the risks and benefits of each treatment option, and your chances of recovery based on each treatment. Each different type of treatment option works differently in terms of the side effects that may occur.  This information will make it easier for you to choose a treatment option that fits your needs and budget.

You need to have realistic expectations with your doctor after a cancer diagnosis. Your doctor will want to make sure that you understand all your options and are aware of all of the possible side effects and complications associated with your treatments. Any concerns about your condition or treatment should be raised with your doctor right away. Never undergo a cancer treatment unless you’ve fully understood what’ll happen before, during, and after the treatment.

Ask For Follow-Up Tests

Patients who follow-up regularly are less likely to experience any complications from cancer treatments. They also have more opportunities to avoid complications as they’re able to monitor their health. Thus, after a cancer diagnosis, it’s important to follow-up on a regular basis for several months to make sure the treatment is working and that the cancer isn’t growing or becoming too rampant.

You can also ask your doctor if you’re going to pay for a full body MRI cost or undergo other kinds of tests, such as biopsy and bloodwork, so they can learn more about your cancer and recommend the appropriate treatment option. You can also take the results of these tests to another doctor to get a second opinion before you decide on which treatment option to undergo.

Explore Treatment Options

Many people think that the only option that they have when they’re diagnosed with cancer is surgery, but this is not always the case as there are many different things that you can do to help improve your quality of life and make sure that you get better.

Here are some treatment options you can opt for after you’ve been diagnosed with cancer:

• Radiotherapy – Many people choose to undergo chemotherapy in conjunction with radiotherapy so that they can speed up the recovery time. Radiation therapy is another type of treatment that’s used to treat many different types of cancer. This treatment option uses high doses of radiation as an attempt to shrink tumors and kill the cancer cells present in the body.If you choose to undergo radiotherapy as your cancer treatment, expect that you’ll be visiting your doctor for months because it’ll take some time before the cancer cells react to this treatment. Once this happens, the cancer cells will be broken down and removed from the body.
• Chemotherapy – This is the main treatment that doctors use for treating cancer. It’s used to treat cancer cells and is usually taken in the form of a pill, which is known as ‘Oral Chemotherapy.’ When the medication is taken, it helps kill off the cells that are causing the problem in the first place.It’s vital that you know how the medication is taken so that you don’t suffer any side effects. Take note that the amount of time that it’ll take for the drug to be effective will vary.The side effects of chemotherapy depend on the type of drugs that you’ve taken. Usually, the symptoms are nausea, vomiting, loss of appetite, and depression.
• Surgery – This is another option if your doctor has recommended it. Although surgery is a serious option, it’s still one often recommended if your doctor feels that the cancer has spread too far.Some surgeries are often combined with other forms of treatment, such as chemotherapy and radiotherapy. The type of surgery you receive will depend on what type of cancer you have, as well as how advanced your cancer is.

Conclusion

Cancer can affect anyone at any time in their lives. Get as much information as possible before choosing the method that’ll suit your particular circumstances best. It’s important to talk to your doctor and get a proper diagnosis and treatment. This will help prolong your life and treat the cancer properly.

The earlier you get the diagnosis, the better chance you have of stopping the cancer from getting worse. Your doctor will give you the treatment options that you may want. Some people with cancer may choose surgery and radiation, but they may also want to undergo chemotherapy.

The Most Effective Ways to Treat MDD

Major Depressive Disorder (MDD) is a serious condition which requires an accurate diagnosis and treatment plan. Confirmation of MDD is possible by way of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a complete psychiatric evaluation, a physical exam, or laboratory tests. Depression is a broad spectrum mental health condition which can present with multiple features, including peripartum or postpartum depression, seasonal depression, depression characterized by psychotic episodes, depression with related anxiety, depression with the extreme melancholy, and atypical depression, et al.

Major Depressive Disorder treatment options vary between types. For the most part, people with depression generally respond favorably to psychotherapy and medication. A general practitioner (primary care doctor) can prescribe medication to relieve the symptoms of depression. Common medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). There are other medications available for treating depression including antipsychotics, mood stabilizers, monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants.

Medications are often associated with side effects, the severity of which will vary from one medication to the next and from patient to patient. SSRIs are generally well tolerated in patients, with minimal side effects. Examples of SSRIs include Prozac, Lexapro, Celexa, Paxil, and Zoloft. SNRIs such as Effexor, Fetzima, and Cymbalta have other side effects such as dizziness, blurred vision, nausea, agitation, constipation/diarrhea, and appetite-related issues. MAOIs such as Parnate, Marplan, and Nardil are usually prescribed when the other medications don’t work. Side effects can be more serious, including dizziness, insomnia, nausea, headaches, drowsiness, and irritation.

Different Types of Therapies for Treating Major Depressive Disorder (MDD)

Whatever medication is prescribed, it is imperative that patients discuss with doctors (primary care doctors or psychiatrists) any complications or difficulties that they experience. Under no circumstances should patients summarily discontinue antidepressant medication without first discussing this with a doctor. Medication is often touted as the best medical approach to treating depression, but it should be seen as one of many options that are now available for treating MDD.

Other treatments include therapy, such as transcranial magnetic stimulation (TMS) which is highly effective when antidepressant medications don’t work. TMS therapy is the latest FDA-approved treatment for MDD. It involves a magnetic coil which is placed near the patient’s forehead, while magnets are strategically positioned to target the areas of the brain which are most likely to benefit from electromagnetic treatment. This is widely regarded as the most effective, non-invasive, non-surgical, non-intrusive, pain-free procedure that is available. A typical TMS treatment regimen requires a 1-hour-long initial visit, followed by 20-30 TMS sessions of 45 minutes, 5 days a week for 4-6 weeks.

Electroconvulsive therapy (ECT) uses electrical currents to pass through the depressed patient’s brain to impact the functionality of the neurotransmitters. This is to alleviate the symptoms of depression, particularly for people who are not responding well to the medication treatments. If a patient is at high risk of suicide or self-harm, ECT is widely recommended. According to Psychiatry.Org, Electroconvulsive Therapy (ECT) is effective for treating patients with bipolar disorder and major depression. This electrical stimulation of the brain has to be performed while the patient is anaesthetized. In attendance are a physician assistant (PA), nurse, anesthesiologist, and a psychiatrist. Statistics show that up to 80% of people treated via ECT experience a marked improvement in depression. While effective as a treatment, ECT is not regarded as a cure for other mental health conditions.

Another treatment option available to patients is ‘Vagus Nerve Stimulation’ or  (VNS). Initially designed for seizures, VNS is also highly effective at treating MDD and related disorders. This surgical procedure requires the implantation of an EPG (Electrical Pulse Generator) under the skin in the chest area. This treatment option provides pulsing electrical stimulation to the vagus nerve. According to NCBI, pulse generators in the chest wall and electrodes attached to the vagus nerve in the neck is an adjunctive treatment for ‘chronic and recurrent depression’. Neuromodulation is now coming into its own as a generally accepted therapeutic field for psychiatric treatment.

Solidarity HealthShare (SHS), a non-profit, affordable, ethical healthcare sharing ministry alternative to traditional health insurance has partnered with Cancer Treatment Centers of America® (CTCA) to provide its members access to world-class affordable cancer care.

“The addition of CTCA as a preferred Oncology Provider will give our members national access to unparalleled cancer care at a significantly reduced price. Both organizations share the passion and value of offering exceptional care that is effective and affordable,” said SHS President, Chris Faddis.

CTCA is a national oncology network of hospitals and outpatient care centers offering an integrated approach that combines surgery, radiation, chemotherapy, immunotherapy, and advancements in precision medicine with supportive therapies to manage side effects and enhance the quality of life during treatment and into survivorship.

“As a nationally accredited and recognized leader in quality and patient satisfaction, CTCA is proud to partner with forward-thinking organizations like Solidarity HealthShare as its preferred oncology provider to ensure its members have direct access to our world-renowned model of care delivered in a cost-effective manner,” said CTCA Chief Strategy Officer, Linde Finsrud Wilson.

With this partnership, our members have direct access to high-quality cancer care at fair and just rates across the nation. Their dedicated patient advocates stand ready to assist any of our members should they find themselves needing CTCA’s services,” said SHS’s Chief Medical Officer, Dr. John Oertle.

“CTCA will allow our members unprecedented access to world class cancer care at affordable costs. This relationship will provide our members with more healthcare options while decreasing medical expenses,” said SHS CEO, Bradley L. Hahn.

Solidarity HealthShare is a Christian healthcare sharing ministry that offers its members an affordable and ethical way to pay for healthcare. Based on the social and moral doctrine of the Catholic Church, we protect our members’ well-formed consciences by sharing in the costs of life-affirming healthcare, and by refusing to participate in unethical medical practices. Our mission is to restore and rebuild an authentic culture that promotes the sanctity of all human life, while facilitating the sharing of our members’ medical expenses.