Denial Rates Research Articles

Hepatitis B Infection: A Mixed Methods of Disclosure Pattern and Social Problems in the Nigerian Family.

Background:Hepatitis B virus (HBV) infection has a high prevalence rate in Nigeria. Disclosure of infection status to close partner and the public attracts support for infected people. This study looks at disclosure and social challenges of infected persons.Methods:Mixed methods of patients’ administered questionnaire and an in-depth interview conducted on HBV-infected respondents in a hospital in Nigeria were used. The study recruited all participants who satisfied the inclusion criteria. Data were entered into SPSS version 20 and analyzed using simple and inferential statistics and content analysis for the in-depth interview.Results:A total of 205 participants completed the questionnaire study. Mean (standard deviation) age was 35.3 (±11.0) years. There were 121 married, 37 singles with noncohabiting partners and 47 singles without partners with disclosure rates being 96.7% versus 97.9% versus 89.2%, respectively. Singles disclosed infection more to their parents while married respondents disclosed infection more to their spouses. Singles had high rate of denial of sexual relationship (22.6%), emotional trauma (34.5%), broken relationships (11.4%), and surreptitious use of contraception for protection (67.6%). Married respondents had the highest rate of HBV vaccination of their family members (40.1%). Infection prevention and allaying fears of family members were their counseling needs. In-depth interview revealed that infected respondents usually expressed shock and depression at a positive test leading to fear and deception that put close associates at risk.Conclusion:Hepatitis B virus–infected respondents have high rate of disclosure. Family problems of these people can therefore be solved through public enlightenment and individual counseling.

The financial impact of the medical toxicology specialty code on a private practice

Background: We describe the financial impact following the implementation of this unique specialty taxonomy code after October 1, 2017 on an established private medical toxicology practice.Methods: Clinical financial data over a 1-year period (October 2016 through September 2017) prior to medical toxicology specialty CMS code implementation was compared to financial data (October 2017 through September, 2018) following implementation. The encounters were billed by current procedural terminology (CPT) codes through the same biller during these time periods. Initial claim denial data were tracked throughout the appeals process.Results: Overall, our initial denial rate decreased by 1.2% (with Medicare denials decreasing by 1.6% – excluding eligibility denials), resulting in a corresponding increase in a clean claim rate of 1.2%. This saved our practice $5477, between the 2 fiscal years.Conclusions: Medical toxicology specialty code implementation had an improved effect on our reimbursement denial rate to our practice.

The Discrepancy Between Palliative and Oncology Providers in Palliative Referrals (QI704)

1.Justify the need for palliative care consultation to outpatient oncologists by meeting with them on a regular basis in order to increase the rate of referrals.2.Identify other patient-centered outcomes as a result of proactive palliative care consultation, including rate of completion of advance directives, rate of state-authorized portable orders (SAPO) completion, and rates of in-hospital and community deaths. According to NCCN and ASCO guidelines, there is evidence that early palliative care consultation in patients with advanced cancer led to significant improvement in quality of life, mood and longer survival as compared to patients receiving standard care. To improve the rate of palliative care consultation by 20% in patients with advanced cancer over a 15 month period at Buffalo Veterans Affairs Medical Center (VAMC). Buffalo VAMC is an academic center affiliated with the University at Buffalo. We provide both outpatient palliative and oncology services. In 2017, we decided to seek proactive palliative care consultations (PPCC) with advanced cancer patients; defined as stage 4 lung cancer, any pancreatic cancer, or any cancer with more than 1 emergency, hospital or ICU admissions. Based on our root analysis our intervention was a meeting between palliative and oncology services once a week since 01/01/2017 to 3/30/2018 at the VA and reviewing the oncology cases on weekly basis with average 80-100 patients per week. From 163 patients requested to be seen by palliative team, oncologists approved 63 proactive palliative consults with denial rate of 60%. PPCC resulted in an increase of referrals by 33% over a 15 month period. Of those patients seen by outpatient palliative care, 92% died in a community setting (hospice or home) while those identified but denied PPCC died in the community setting only 50% of the time. Interestingly, patients whose PPCC were denied but were later seen by the palliative care team during a hospital admission died in the community 91% of the time. In addition, advanced directives and SAPO increased by 30% and 65% respectively. Seeking proactive palliative care consultation in patients with advanced cancer led to an increased outpatient referral rate with a simultaneous decrease in in-hospital mortality.

Insurance Approval for Proton Beam Therapy and its Impact on Delays in Treatment

Prior authorization (PA) has been widely implemented for proton beam therapy (PBT). We sought to determine the association between PA determination and patient characteristics, practice guidelines, and potential treatment delays. A single-institution retrospective analysis was performed of all patients considered for PBT between 2015 and 2018 at a National Cancer Institute-designated Comprehensive Cancer Center. Differences in treatment start times and denial rates over time were compared, and multivariable logistic regression was used to identify predictors of initial denial. A total of 444 patients were considered for PBT, including 396 adult and 48 pediatric patients. The American Society for Radiation Oncology model policy supported PBT coverage for 77% of the cohort. Of adult patients requiring PA, 64% were initially denied and 32% remained denied after appeal. In patients considered for reirradiation or randomized phase 3 trial enrollment, initial denial rates were 57% and 64%, respectively. Insurance coverage was not related to diagnosis, reirradiation, trial enrollment, or the American Society for Radiation Oncology model policy guidelines, but it was related to insurance category on multivariable analysis (P<.001). Over a 3-year timespan, initial denial rates increased from 55% to 74% (P=.034). PA delayed treatment start by an average of 3weeks (and up to 4months) for those requiring appeal (P<.001) and resulted in 19% of denied patients abandoning radiation treatment altogether. Of pediatric patients, 9% were initially denied, all of whom were approved after appeal, and PA requirement did not delay treatment start (P=.47). PA requirements in adults represent a significant burden in initiating PBT and cause significant delays in patient care. Insurance approval is arbitrary and has become more restrictive over time, discordant with national clinical practice guidelines. Payors and providers should seek to streamline coverage policies in alignment with established guidelines to ensure appropriate and timely patient care.

Real Denial Rates: A New Tool to Look at Who Is Receiving Mortgage Credit

ABSTRACTThe observed mortgage denial rate (ODR), calculated from Home Mortgage Disclosure Act (HMDA) data, is often used to measure mortgage credit availability, but it does not account for shifts in applicants’ credit profiles. In this article, we develop an additional tool, which we call the real denial rate (RDR), as a way to account for credit differences and hence more consistently measure denial rates and mortgage credit accessibility. We match HMDA data with CoreLogic proprietary data to obtain both borrower demographic information (e.g., income and race and ethnicity) and mortgage credit characteristics (e.g., loan-to-value ratios, debt-to-income ratios, and credit scores). We account for shifts in applicants’ credit profiles by considering only the denial rate of low-credit-profile applicants. Our RDR results show that conventional mortgages have higher denial rates than government mortgages do, racial and ethnic differences are smaller than the ODR indicates but are not eliminated, and small-dollar mortgages have higher RDRs, particularly in the government loan channel.

Securitization, bank behaviour and financial stability: A systematic review of the recent empirical literature

We systematically review the recent empirical literature to investigate whether and how securitization influences bank behaviour and its implication on financial stability. We find that, in the years preceding the 2007–2009 financial crisis, banks with higher credit and market risk were more likely to securitize assets. Banks became riskier and increased systemic risk as they took advantage of securitization in order to obtain capital relief. There is robust evidence indicating that mortgage securitization led to a deterioration in bank lending standards via weaker screening, lower denial rates, and misreporting of credit quality. For corporate loan securitization, the empirical findings on lax bank lending are inconclusive. However, it is evident that securitization resulted in poorer ex-post bank monitoring of corporate borrowers. Even though Europe is the second largest securitization market, there is a dearth of evidence on the impact of securitization on European banks' lending behaviour. Research is also very limited on the post-crisis regulatory incentive aligning mechanisms such as the risk retention requirements and the credit ratings reform. Finally, evidence on securitization activity in emerging markets, such as Latin America and China, where securitization volumes have been increasing recently, is relatively non-existent.

Geographical surveys, analytical services ambient levels of some residential units in Anbar province

It came Search to provide an explanation scientifically it discusses the levels of some services within the province of Anbar, environments, and the development of appropriate indicators to determine the extent of disadvantage housing services, was distributed deprivation levels of services on parts of the province to determine the cause of variation and its implications for the development of solutions and treatments. The dependence style of the field study and the distribution of the questionnaire and the relevant departments data, as well as desktop sources, and the main findings of the research show that the rate of denial of the level of the surrounding housing services for over 50% of the pan-Anbar province, and varies in its distribution among the districts of the province and their environments, which stands Rah reasons for planning, regulatory and signatories and social. Find crowned geographic vision which can be some glitches diagnosed appropriate treatment mode.

Impact of specialty pharmacist involvement on patient access to PCSK9 inhibitors

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are novel antilipemic agents commonly associated with barriers to access for patients. They are indicated as adjunctive therapy for the treatment of heterozygous familial hypercholesterolemia, homozygous familial hypercholesterolemia, and atherosclerotic cardiovascular disease needing additional low-density lipoprotein cholesterol (LDL-C) lowering. On average, annual therapy costs total approximately $14,000 per year. Due to high cost and specific indications, rates of prescription coverage denial are high for patients prescribed these medications with approximately 50% of prescriptions ultimately being rejected.Objectives: The purpose of this study is to demonstrate the impact of specialty pharmacist involvement on patient access to PCSK9 inhibitors.Methods: This was a retrospective study of patients over the age of 18 who were prescribed a PCSK9 inhibitor by a Medical University of South Carolina (MUSC) provider, with additional training in lipid management or cardiology, from 1 January to 30 June 2017. Patients were excluded if they were actively enrolled in a clinical trial at the time of PCSK9 inhibitor prescribing, or they were pregnant or lactating.Results: A total of 76 prescription orders were included in the analysis. The results were divided into three categories and compared to industry standards via chi-squared goodness of fit tests. Overall, 34/38 (89.5%) prescriptions were eligible to be filled at MUSC, statistically significantly higher than the expected 30.9% overall fill rate (p < .001). Additionally, 50/57 (87.7%) of prescriptions requiring a prior authorization (PA) and sent to MUSC received approval, statistically significantly higher than the expected 47.29% approval rate (p < .001). Lastly, 28/31 (90.3%) of patients received medication and a PA, statistically significant compared to 65.3% expected (p = .003). Regarding clinical outcomes, 35/38 patients (92.1%) in the MUSC eligible fill group did not have an unplanned cardiovascular-related emergency department visit or admission.Conclusions: As specialty pharmacy continues to grow and diversify, costly medications, like PCSK9 inhibitors, will continue to require added steps to obtain them. In this study, dedicated specialty pharmacists increased patient access to PCSK9 inhibitors by 58.6% compared to expected. This not only demonstrated improved quality of care, but also positive impacts on clinical outcomes, especially in patients who maintain the continuum of care through the health system.

191 Outcomes and Cost: A Retrospective Analysis of Admissions to a Pediatric Observation Unit Versus Inpatient Hospitalization

Many pediatric patients requiring inpatient admission are otherwise healthy children with self-limited illnesses and discharged within 48 hours, making them ideal candidates for care in a pediatric observation unit (POU). Respiratory illnesses remain a leading cause for hospital admission and there have been recent changes in the management of these conditions. Differences in patient outcomes for admission to a POU versus a pediatric inpatient unit (PIU) have not been thoroughly evaluated. We determine differences in length of stay (LOS) and cost between children being admitted to a pediatric observation unit and a traditional inpatient unit. In January 2017, pediatric inpatient beds were moved from an urban, academic, community hospital to an off-site tertiary academic children’s hospital. Subsequently, a pediatric observation unit (POU) was opened adjacent to the pediatric emergency department. In this retrospective observational cohort study, eligible subjects included children 0-18 years old who met criteria for admission to the POU. As the units were not concurrently open, data was collected from January through June 2016 for children admitted to the PIU and January through June in 2017 for children admitted to the POU to control for seasonal variation in admissions. Information regarding the current illness, past medical history, treatment in the PED, and course in the POU or PIU were collected. The hospital LOS was analyzed as the primary outcome. Changes in level of care and composite hospital costs and denials data were collected as secondary outcomes. Data from 116 admissions have been analyzed, 65 admitted to POU and 51 to PIU. Group characteristics are listed in Table 1. The mean LOS was 25.0 hours, 95% CI [21.5, 28.5] for the POU group and 64.5 hours, 95% CI [54.6, 74.5] for the PIU group (p<0.01). Three patients in the POU group were subsequently transferred to the PIU, none were transferred from the POU to the intensive care unit (ICU), and 1 patient was transferred from the PIU to the ICU. The physician staffing cost to patient ratio was $2,293 for the PIU and $2,403 for the POU. The payer denial rate for PIU and POU was 10.0% and 0.6%, respectively, for visits less than 48 hours. Children admitted to the POU appeared to have a significantly shorter LOS compared to those admitted to a PIU without more complications. Pediatric observation units may provide the means toward cost-efficient, patient-centered care for children with illnesses requiring brief hospitalizations.Tabled 1Patient characteristicsPOUPIUTotal Enrolled6551Male (%)31 (47.7)26 (51.0)Age in years (SD)6.2 (5.1)7.2 (5.7)Respiratory Illnesses (%)43 (66.2)31 (60.8)Illness days (SD)3.5 (2.6)2.6 (2.6)Previous Hospitalizations (SD)1.4 (1.2)0.3 (1.1) Open table in a new tab

Volume and Coverage of Secondary Imaging Interpretation Under Medicare, 2003 to 2016

PurposeThe aim of this study was to assess changing Medicare volumes of, and coverage for, secondary interpretations of diagnostic imaging examinations stratified by modality and body region service families. MethodsMedicare Physician/Supplier Procedure Summary Master Files for 2003 to 2016 were obtained. Aggregate Part B fee-for-service claims frequency and payment data were isolated for noninvasive diagnostic imaging and stratified by service family. Using published Medicare payment rules, secondary interpretations were identified as studies billed using both modifiers 26 and 77. Billed and denied services volumes were calculated and compared across modality and body region service families. ResultsSeven service families showed a compound annual growth rate from 2003 to 2016 of >20% (an additional 12 service families, >10% growth). For select high-volume service families (chest radiography and fluoroscopy [R&F], brain MRI, and abdominal and pelvic CT), relative growth in billed secondary interpretation services exceeded that for primary interpretations. In 2016, body region and modality service families with the most billed secondary interpretations were chest R&F (674,124), abdominal and pelvic R&F (65,566), brain CT (45,642), extremity R&F (34,560), abdominal and pelvic CT (14,269), and chest CT (10,914). All service families had secondary interpretation denial rates <25% in 2016 (15 service families, <10%). ConclusionsAmong Medicare beneficiaries, the frequency of billed secondary interpretation services for diagnostic imaging services increased from 2003 to 2016 across a broad range of modalities and body regions, often dramatically. Payment denial rates were consistently low across service families. As CMS continues to seek input on appropriate coverage for these services, these findings suggest increasing clinical demand for and payer acceptance of these value-added radiologist services.

Migration policy: did an emergency provision displace standard rules? Evidence from Italy

In 2011, to manage the exceptional flow of people escaping North Africa, the Italian government released the North Africa Emergency (Emergenza Nord Africa, ENA) provision, temporarily relaxing migration policies for some categories of asylum seekers. Using data from an important charity, we perform baseline difference-in-differences regressions to investigate the impact of this emergency rule on the probability of migrants regularizing their legal status. We exploit the timing of the enactment of the ENA accessibility criteria—such that potential beneficiaries learned of its existence only after the realization of the state of entitlement—to identify the effects of the emergency policy provision on treated and control groups of immigrants. The results show an increased number of successful applications in favor of eligible individuals, although a dramatic boost in the denial rate for other migrants is also observed. This suggests either that some migrants suffered displacement due to the emergency rule, and/or that improper submissions of ENA-oriented applications have occurred. We extend our analysis to the use of multilevel models to shed light on these possible (non-mutually excludable) explanations. Results seem to support the presence of some rule-displacement effects, although the existence of a set of wrongful submissions cannot be excluded. We discuss these possibilities from a policy perspective.

543 Evaluating the burden of prior authorization in the treatment of psoriasis

(PAs) compared to other medical specialties and even primary care practices. A recent survey study revealed an increasing number of PAs being required over the past year, and the negative effects on patients include delaying or preventing proper treatment. This is especially problematic for psoriasis patients. Psoriasis affects over 7.4 million people in the United States, and many remain untreated or undertreated. We conducted a retrospective review of all dermatology visits in an academic practice from May 1, 2017 to July 31, 2017 to investigate the PA burden in psoriasis and other dermatologic conditions. Of all prescriptions written during this time period (n=4862), psoriasis prescriptions had a higher requirement for PA as compared to non-psoriasis prescriptions (14.0% vs. 8.9%, p=0.001). Of psoriasis PAs, 32% were for biologic agents. Time to process PAs from the time of initiation to time of decision was similar for psoriasis versus non-psoriasis prescriptions (8.4 days vs. 8.8 days, p=0.8). The denial rate for psoriasis PAs was higher but not statistically different as compared to non-psoriasis PAs (30% vs. 25%, p=0.363). The most common psoriasis prescriptions that required PA were clobetasol, adalimumab, tacrolimus, and apremilast. The most common reasons for PA denial were step therapy required or non-formulary medication. Our study shows that prescriptions written for psoriasis require PAs at a higher rate than other dermatologic conditions. The increased requirement for PAs for psoriasis may contribute to psoriasis undertreatment and is likely partially due to the availability and high cost of biologic agents. With further development of biologic agents for psoriasis and other dermatologic conditions, the PA burden for dermatology will likely continue to increase. Further studies are needed both to evaluate processes that streamline PAs and to examine the impact of the burden of dermatology PAs on patient treatment outcomes and administrative healthcare costs.

The Complexity Of Billing And Paying For Physician Care.

The administrative costs of providing health insurance in the US are very high, but their determinants are poorly understood. We advance the nascent literature in this field by developing new measures of billing complexity for physician care across insurers and over time, and by estimating them using a large sample of detailed insurance "remittance data" for the period 2013-15. We found dramatic variation across different types of insurance. Fee-for-service Medicaid is the most challenging type of insurer to bill, with a claim denial rate that is 17.8 percentage points higher than that for fee-for-service Medicare. The denial rate for Medicaid managed care was 6 percentage points higher than that for fee-for-service Medicare, while the rate for private insurance appeared similar to that of Medicare Advantage. Based on conservative assumptions, we estimated that the health care sector deals with $11billion in challenged revenue annually, but this number could be as high as $54billion. These costs have significant implications for analyses of health insurance reforms.

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Disaster Lending: The Distributional Consequences of Government Lending Programs

We find the Small Business Administration's disaster-relief home loan program denies significantly more loans in areas with larger shares of minorities, subprime borrowers, and higher income inequality. We find that risk-insensitive loan pricing -- a feature present in many regulated and government-run lending programs -- is a primary driver of these disparities in access to credit. The differences in denial rates are disproportionately high compared to private-market lending and government-insured risk-sensitive loan pricing programs. Thus, despite ensuring fair prices, the use of risk-insensitive pricing may lead to unfair access to credit.

Outcome of children born after pregnancy denial

IntroductionDenial of pregnancy remains a phenomenon little known to healthcare professionals. Yet its repercussions are far from negligible. The aim of this study was to assess whether denial of pregnancy has an impact on the infant's development. Patients and methodThis prospective study included 51 full-term infants born in Nancy Regional Maternity Hospital between 1 January 2009 and 30 June 2015. In this study, the development of the children was followed longitudinally. We collected data during the neonatal period, at 9months, and at 2years of age from the infants’ file and standardized medical certificates, and current data through a telephone questionnaire. Three fundamental aspects of the infants’ development were analyzed: height and weight growth, psychomotor development, and the existence of pathologies. Given that this was a preliminary study aiming at exploring facts, no statistical tests were carried out. ResultsThe rate of denial of pregnancy was one birth in 300 during the study period. These infants showed proportional intrauterine growth restriction, which leveled out later, with their height and weight growth normal by month 9. The full-term perinatal mortality rate was 5%. The infants showed no sign of increased morbidity; 20% of them presented with delayed psychomotor development at 9months of age, with an increased impact as they grew older. The rate reached 30% after 24months, half of which were language disorders. ConclusionThe results of this preliminary study point out the need for thorough monitoring of these infants throughout infancy.

The conditional spatial correlations between racial prejudice and racial disparities in the market for home loans

Many studies have shown the existence of disparities in loan denial rates between blacks and whites that cannot be accounted for by observable applicant characteristics. Examining the link between racial gaps in home loan denial rates and prejudicial attitudes toward blacks measured by questions in the General Social Survey, this article shows not only that blacks are more likely to be denied conventional home mortgages but that denial rates among blacks for these loans are also geographically correlated with racial prejudice, particularly among first-lien home purchase loans and loans from depository lenders. However, among Federal Housing Administration-insured loans guaranteed by the government in the event of borrower default, this study finds no evidence of a statistical relationship between racial prejudice and loan denials among black applicants. Results are consistent with taste-based discrimination by discriminatory lenders; however, one cannot rule out that statistical discrimination is at least partially driving the results.

Evaluating Options For The Regulation Of Payday Loans

This study discusses regulatory options that federal and state legislatures might consider for the payday loan industry. These options include outright prohibition; restricting the implicit annual percentage interest rate; limiting the amount per loan; limiting the number of concurrent loans; setting lower and upper limits on contract length; and defining the waiting period between loans. While other studies examining the payday loan industry have relied on user survey data or data from a specific lender, this study utilizes data collected by the administrative agent for all payday loan activity in several states, including Florida, Illinois, and Oklahoma. A comparison of key empirical results derived from the differing regulatory environments in these states provides guidance to those who consider imposing further regulation. The current regulatory constraints have resulted in a relatively low default rate, a high rate of loan denial, and a troubling industry reliance on the frequent borrower. An analytical framework is suggested for understanding the motivations of the low and high frequency borrowers.

Lending Standards and Macroeconomic Dynamics

This paper proposes a tractable way to incorporate lending standards (credit qualification thresholds) into macro models of financial frictions. Banks can reject borrowers whose risk is above an endogenous threshold at which no lending rate sufficiently compensates banks for the borrowers’ default risk. Firms denied credit cut employment and labor reallocates mostly towards safer producers. Lending standards propagate bank capital shortfalls through labor misallocation causing deeper and more persistent real effects. The paper also shows that lending spreads are insufficient indicators of credit supply disruptions. That is, for the same increase in credit spreads, output falls faster when denial rates are increasing. Finally, with endogenous lending standards, first-moment bank capital shocks look like second-moment shocks. JEL Classification: E32, E44, E47, G2

Local specialty pharmacy and specialty clinic collaboration assists access to hepatitis C direct-acting antivirals

ObjectivesTo measure prescribed time to therapy (TtT) and sustained virologic response (SVR). Secondary objectives were to assess insurance appeals and copay assistance amount facilitated by a local specialty pharmacy (LSP). MethodsThis descriptive, retrospective study used a joint clinical and pharmacy database of patients who were prescribed direct-acting antivirals (DAAs) at a single-center liver specialty clinic and received LSP services from December 2013 to December 2015. ResultsAmong 388 patients prescribed DAAs, 364 (94%) patients, who were 18 years of age or older, initiated DAA therapy, and received LSP services, were included in the study. Of these, 211 (58.0%) had cirrhosis, 159 (43.7%) had previous treatment, and 57 (15.7%) had previous liver transplants. Most patients had commercial insurance (n = 249; 68.4%), and 295 (81.0%) required prior authorization. Insurance initially denied coverage to 70 patients (19.2%), for who the LSP drafted appeals for 60 (85.7%). Copay information was available for 154 LSP patients. Although 66 had initial copays of more than $20 per month, the LSP was able to assist most (98.1%; n = 151) with copay reductions to $20 or less. Full financial assistance was received for 20 patients without insurance or any DAA coverage. Among 171 patients with SVR and prescribed TtT information, mean TtT was 12 days (median 4 days), and most received medications within 10 days (n = 122; 71.3%). The overall intention-to-treat SVR rate was 86.8%; the per-protocol (PP) SVR rate was 93.8%. ConclusionCollaboration between providers and an LSP minimized delay in therapy, lowered rates of DAA denial, facilitated patient financial assistance, and helped to optimize clinical outcomes. The PP-SVR rate for this study was similar to rates reported in the literature and higher than expected, considering the inclusion of earlier-generation DAAs and many patients with advanced liver disease.