The Game of Claim Denial: Commercial Insurers’ Tactics Revealed • Co-founders of GoHealth Launch Takeover Bid • Seventh Approval for Rinvoq

HOW COMPANY INSURERS SQUEEZE PROVIDERS:Hospitals in Illinois and across the country are struggling to collect payment for health care services they have provided. This is especially true among commercial payers.

In the first quarter 2023, Medicare denied 3.9% of claims for inpatients and outpatients while commercial payors initially denied 15.1%.

Illinois providers do slightly better when it comes to commercial insurance. Colleen hall, managing principal at Crowe, stated that the initial denial rates for commercial payors in Illinois were 11.6% and Medicare was 4.4% in the first three months of the year.

The report states that about 45% (or more) of the typical hospital patient population have health insurance with a commercial carrier.

The report says that commercial payors reimburse providers at higher amounts per case compared to traditional Medicare. However, failure to pay on time directly affects hospitals’ financial performance.

Hall says that commercial payers hold out by denying care or initially denying but later approving. She said they also use takebacks where payment is made, but claims are reviewed to get back some of that money.

Hall, managing principal at Crowe’s health care group, said that historically, commercial insurers paid claims more quickly than government plans due to less red tape. However, it has become increasingly difficult for providers of healthcare services to receive payment. How can hospitals expect to recover financially when payors who account for nearly half of their business hold onto a quarter of their claim payments for over 90 days?

Hall stated that the picture painted was of a provider who is almost defeated.

She said that more than a tenth of the times, when a provider submits a reimbursement claim for patient care, the answer is “no”. “It’s your responsibility to find the needle in the stack and resubmit the claim,” she added. She said that the time and energy spent on resubmitting a claim is costly and not reimbursed.

Crowe’s clients are told that the most important thing to learn from this report is: “If your claim is denied, you need to fight for them,” Hall said. Hall says that the first thing you should learn from this report is: “If you are denied your claim, then fight for it,” Hall stated. Hall said that “oftentimes, the discouragement of providers is a factor in whether or not a denial will be approved.”

Blue Cross & Blue Shield of Illinois is the largest commercial health insurance company in the state. However, they declined to comment on the Illinois specific figures.

AHIP (America’s Health Insurance Plans) did not respond by the deadline set by Health Pulse to a comment request. The national health insurance advocacy organization stated in an that “too much of our nation’s healthcare dollars are wasted by unnecessary, inappropriate, or even harmful treatment.”

Prior authorization is crucial to ensure that patients can access clinically appropriate and evidence-based treatment. Prior authorization can help reduce the inappropriateness of care by detecting unsafe or low value care, or care that does not match up with the most recent clinical evidence. This will prevent unnecessary costs for patients and harm.

AHIP acknowledged that PA can be a burdensome process for providers. They suggested increasing adoption of electronic pre-approval as a means to improve PA.

Crowe’s Hall stated that the company provides hospitals with their specific data about denials from payors as well as the regional average. Hall explained that providers should go to their payers armed with the data and tell them, “I am not okay with this.”

“For the most part, providers and payers are so far apart that these conversations don’t happen.” Hall stated that some hospitals have a good rapport with insurers and hold productive round-table conversations.

GOHEALTH TAKEOVER BID FROM ITS COFUNDERS : The health insurance marketplace GoHealth received a takeover bid of $20 per share from its two biggest shareholders, Centerbridge Partners, and NVX holdings, according to a company statement released late on Friday.

According to a filing at the U.S. Securities & Exchange Commission, the unsolicited offer is to purchase all of the outstanding Class A common stock.

Clinton P. Jones is the CEO of NVX and Brandon M. Cruz is its president. Both are co-founders of GoHealth and nonexecutive chairs of the board. NVX, Centerbridge and their combined shares control 61%.

After GoHealth’s stock plummeted, Vijay Kotte, the then-CEO was replaced and Cruz, the chief strategy officer became nonexecutive chairperson.

ABBVIE’S RINVOQ GETS CROHN’S DISEASE APPROVALNorth Chicago based AbbVie received a new U.S. Food & Drug Administration (FDA) approval for its antiinflammatory drug Rinvoq.

Rinvoq, as a once daily pill to treat moderately active Crohn’s Disease is the seventh FDA approval in gastroenterology. Rinvoq, along with Skyrizi and other anti-inflammatory drugs, is seen as the revenue-generating replacements for AbbVie Humira. Humira’s market share is being lost to biosimilars.

AbbVie, AbbVie’s Senior Vice President of Research and Development and Chief Scientific Officer, Dr. Thomas Hudson said: “AbbVie is aware of the need for additional treatment options for Crohn’s disease to help both address rapid relief of symptoms and the visible reduction in intestinal lining damages.” We’re happy that Rinvoq is available for treating Crohn’s Disease and may provide relief.

AbbVie announced last week the FDA approved Epkinlytm, a lymphoma treatment. AbbVie claims that it is the “first and only bispecific T-cell antibody for adult patients with diffuse large B cell lymphoma R/R (DLBCL).” The FDA approved the drug under its Accelerated Approval Program based on the response rate and the durability of the response. DLBCL is a fast-growing, aggressive form of non-Hodgkin lymphoma.

“DLBCL can be a cancer that is aggressive and resistant to treatment. EPKINLY’s FDA approval represents a new mechanism of action in treating third-line DLBCL patients. We hope EPKINLY, a single-agent non-chemotherapy treatment for DLBCL, can treat this aggressive cancer and be used quickly by physicians.

ABILITYLAB BRINGS ITS RESOURCES TO MINNEAPOLIS SYSTEM Shirley Ryan AbilityLab, a Chicago-based rehab facility, has formed an alliance with Hennepin Healthcare to offer AbilityLab’s expertise in rehabilitation services to the patients of the Minneapolis system.

The statement stated that Shirley Ryan AbilityLab would deploy leaders to directly work with Hennepin Healthcare leadership and frontline clinical teams. Hennepin Healthcare’s rehabilitation team, inpatient therapy teams, and medical staff remain Hennepin Healthcare’s employees. There will be no interruption or change in employer affiliation or labor status. The system’s core is HCMC in downtown Minneapolis. It is a Level I trauma center, both for adults and children, and a teaching and research hospital.

In a statement, Jennifer DeCubellis said that the Hennepin Healthcare CEO was pleased to announce the alliance. “This partnership brings the expertise of one of the best rehabilitation hospitals in the United States to Hennepin Healthcare patients from Minnesota and throughout the region.”

AbilityLab stated that the alliance with Hennepin is in line with its expansion strategy, and it adds another health care teaching and research system as a new partner.

REOPENING MENTAL HELPFUL CLINICS IN THE CITY IS NOT EASY While Mayor Brandon Johnson took concrete steps to care for Chicagoans suffering from mental illness in his inaugural speech last week, details are still fuzzy about how and whether his administration plans to reopen the six mental health centers run by the city, according Alex Nitkin, of Illinois Answers Project.

Johnson stated about 30 minutes into the speech that he wanted to ensure that no one would ever suffer for not having access to mental healthcare services. “Let’s bring the private and public sectors, as well as the county, state, and federal governments together to find the most effective solutions for providing these services. This includes reopening mental health centers in Chicago.”

“We want to (reopen) mental health clinics. But I think we need to also reimagine how these clinics could look,” said Ald. Rossana Rodriguez Sanchez, 33rd Ward, is a close ally to the new Mayor and likely the next chair of City Council Committee on Health & Human Services.

At this point, it is important to determine the greatest need. Rodriguez-Sanchez said. It might not be exactly the same six buildings — but it might. We’ll need to investigate that.

FDA APPROVES ABBOTT CATHETER: Abbott Laboratories has received FDA approval for the TactiFlex Ablation Catheter with Sensor Enabled.

The FDA approved the North Chicago company the same week that the approval was given.

Abbott announced last week that the catheter is the first to have a flexible tip with contact force technology. This “can lead to reduced procedure times and improved safety when compared with the previous generation catheters of the company,” Abbott stated.

The catheter can be used with Abbott’s EnSite X EP system to perform ablation procedures to treat atrial Fibrillation (AFib).

Dr. Christopher Piorkowski is the chief medical officer for Abbott’s Electrophysiology Business. He said, “Abbott leads the way when it comes to helping doctors manage arrhythmias by offering the most comprehensive portfolio in the world.” The EnSite X EP System has no equal in determining where the ablation procedure is needed. With the TactiFlex Catheter, patients are able to feel more confident in their procedure.

A Glimpse

Illinois Governor J.B. Pritzker has a number of health care bills on his desk. J.B. Pritzker is awaiting the signature of a bill that will make behavioral telehealth for Illinois Medicaid beneficiaries permanent. Senate Bill 1913 was approved by both houses.

Illinois Medicaid patients can continue to receive telehealth behavioral health care remotely. In 2021, the state made telehealth treatment for substance abuse disorder and mental illness permanent.

In a press release, Illinois Association for Behavioral Health CEO Jud Deloss stated that as soon as Governor Pritzker announced the official end date of COVID-19, he knew the continuation of telehealth for Medicaid patients was going to enter an unwelcome, uncertain legal gray area. “Within hours, we had legislation drafted and recruited state senator Laura Fine and state rep. Jenn Ladisch-Douglas to serve as legislative advocates. They expeditiously moved the bill forward.”

Crain’s sister magazine, Crain, reported that the U.S. Drug Enforcement Administration (DEA) has said it will also allow telehealth providers to continue prescribing controlled substances beyond the end date of the emergency for an additional six months without requiring a face-to-face appointment.

The FTC is looking to clarify the rules regarding health data breaches. The FTC, after announcing a settlement agreement with the U.S. Federal Trade Commission, said in a separate press release that they wanted to change the Health Breach Notification Rule so it is clear what protections are extended to digital health app users.

The agency has included health trackers, apps, and other direct to consumer companies in the rule. However, the proposed changes codify the fact that digital health companies who handle medical information will be treated much the same as providers. A spokesperson for the agency said that any unauthorized disclosure will trigger the rule. This includes companies that share user data without the consent of users. Experts say the recent enforcement actions are likely to serve as a warning to digital health companies that share health information.

According to a press release from Kelly’s office, the NIH would be required to work with sponsors of clinical trials to establish clear and measurable goals for recruitment and retention, and to ease some burdensome requirements.

Clinical trials are crucial in improving medical care, advancing knowledge and promoting a better outcome for everyone. The data shows that marginalized groups are excluded from the development of treatments for diseases from which they die disproportionately. Kelly stated in a press release that we can’t tackle health disparities without knowing, having all the facts. “I’m reintroducing the NIH Clinical Trial Diversity Act in order to ensure that all NIH funded trials provide effective and inclusive medical treatments to those who most need them. This bipartisan legislation with Rep. (Brian) Fitzpatrick and Sen. Robert Menendez and Sen. Susan Collins is a great solution to the current health equity crisis.

The National Association of Manufacturers has taken a new hit on the industry of pharmacy benefit managers. They have called for PBMs pass directly prescription drug discounts to employers and employees. In a press release, the association said that PBMs were contributing to skyrocketing drug costs by retaining discounts from drugmakers and not passing them on. PBMs are under federal scrutiny by Congress and federal regulators.

Elizabeth Holmes lost her last request to stay free on bail as she appeals the fraud conviction. Theranos’ founder, Elizabeth Holmes, proposed last week to report to prison on May 30, to begin serving her 11-year term after being convicted last year by a jury of defrauding the investors of the blood-testing company. Holmes won a short pause that delayed the start of her sentence while the court of appeals considered her request. She can appeal her conviction, but she must do it from prison.

Those on the Move

Perkins & Will, an architecture and design company, has appointed Amy Williams to the position of principal and Midwest Regional Health Practice Leader. She has worked for Intermountain Healthcare, Kaiser Permanente, Mayo Clinic and Perkins & Will.

Bill Sivrais , a member of the American Board of Medical Specialties, has been appointed to oversee its technology strategy. This includes cybersecurity operations, data protection, procurement and reporting. Bill Sivrais was previously the chief technology officer of the organization and its director of information technologies.