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<td><span style="font-family:Helvetica, sans-serif; font-size:20px;font-weight:bold;">Health Tech | Fierce Healthcare</span></td>
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<td><a href="https://www.fiercehealthcare.com/sponsored/prior-authorization-todays-innovators-speak-out" style="font-family:Helvetica, sans-serif; letter-spacing:-1px;margin:0;padding:0 0 2px;font-weight: bold;font-size: 19px;line-height: 20px;color:#222;">Prior authorization: Today’s innovators speak out</a>
<div style="font-family:Helvetica, sans-serif; text-align:left;color:#999;font-size:11px;font-weight:bold;line-height:15px;">Apr 6th 2026, 13:45</div>
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<p><p morss_own_score="6.776748971193416" morss_score="159.7767489711934">The fifth annual Abarca Forward conference, hosted by the pharmacy benefit manager (PBM) Abarca Health at its headquarters in San Juan, Puerto Rico, dug into key aspects of prior authorization (PA). The invitation-only event brought together payers, PBMs, specialty pharmacies and clinicians to discuss how evolving technology and improved processes and communication can return PA to its roots of safeguarding patients while reducing healthcare costs.<br></p></p>
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<td><a href="https://www.fiercehealthcare.com/payers/5-major-insurers-vendor-zelis-must-face-repricing-antitrust-claims-judge-rules" style="font-family:Helvetica, sans-serif; letter-spacing:-1px;margin:0;padding:0 0 2px;font-weight: bold;font-size: 19px;line-height: 20px;color:#222;">Antitrust lawsuit against 5 major insurers, Zelis moves forward</a>
<div style="font-family:Helvetica, sans-serif; text-align:left;color:#999;font-size:11px;font-weight:bold;line-height:15px;">Apr 6th 2026, 13:45</div>
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<p><div class="col content" morss_own_score="5.796078431372549" morss_score="65.72239422084624">
<p>Five of the largest health insurers and health tech vendor Zelis must face claims that they conspired to reduce out-of-network reimbursements to healthcare providers, a federal judge ruled on March 30.</p>
<p>Judge Brian E. Murphy of the U.S. District Court for the District of Massachusetts ruled that the plaintiffs, comprising several medical, dental and chiropractic providers from multiple states, plausibly alleged antitrust standing and injury in the case. The judge denied Zelis and the insurance companies' joint motion to dismiss.</p>
<p>The case centers on allegations brought by healthcare providers against Zelis and Aetna, Cigna, Elevance, Humana and UnitedHealth Group that the five major payers conspired to suppress out-of-network reimbursement rates through Zelis' repricing tools.</p>
<p>The litigation began in March 2025, when Pacific Inpatient Medical Group filed a class action lawsuit against Zelis, Aetna, Cigna, Elevance and Humana. The court then consolidated the case with several related actions and the plaintiffs filed an amended consolidated complaint in June.</p>
<p>In the lawsuit, the providers allege that Zelis collaborated with private commercial health insurers and payers, and at least one other competitor, to avoid competition over payment rates for out-of-network healthcare services. </p>
<p>"The conspiracy involves the unlawful agreement, communication, coordination, and information sharing, as engaged in by Zelis and the commercial payer defendants, designed to collusively depress and set payments and payment levels or thresholds for out-of-network healthcare services, euphemistically known as 'repricing.' Even if neutral sounding, such 'repricing' is not based on any pre-payment, provider-payer negotiation, and goes only one direction: down," the providers allege in the lawsuit.</p>
<p>The providers claim that Zelis' tool forces them to either accept the "severely downwardly adjusted amount as payment; to engage in time-pressured and one-sided 'negotiations' with Zelis; or to file an 'appeal' of the downwardly-adjusted claim with Zelis," the providers said.</p>
<p>These options rarely, if ever, result in an increase in the payment and ultimately result in the incursion of an expense in the form of delay, if not a further decrease in payment of the provider’s originally submitted claim, the providers allege.</p>
<p>For example, plaintiff Pacific Inpatient Medical Group alleges that Zelis repriced a claim at a discount of 88%, which the provider said was below market prices.</p>
<p>The providers also claim they had no meaningful ability to negotiate those repriced amounts, and that they were effectively barred from balance-billing patients.</p>
<p>In exchange for its downward adjustment of providers' out-of-network claims, Zelis receives a percentage of the amount that the payer saves, the providers allege in the lawsuit.</p>
<p>Zelis provides a comprehensive array of network management, claims integrity, payment remittance solutions and analytical services to healthcare organizations. The complaint centers on the company's Established Reimbursement Solution and Reference Based Pricing products. The company works with more than 750 payers, including the top five national health plans, regional health plans, TPAs and self-insured employers, and millions of healthcare providers.</p>
<p>When contacted, a Zelis spokesperson said the company does not comment on ongoing litigation.</p>
<p>Insurance Business Magazine reported that Zelis previously denied the accusations, stating the complaints are mistaken about its clients, operations and the benefits it provides.</p>
<p>Vendor MultiPlan is also facing antitrust and consumer protection claims in litigation brought by healthcare providers. Individual health systems and the American Medical Association have filed cases against MultiPlan, leading to multidistrict litigation consolidating dozens of plaintiff complaints. They <a href="https://www.fiercehealthcare.com/payers/judge-denies-multiplan-payers-motions-toss-price-fixing-litigation">accuse</a> the company of forming agreements with insurers—UnitedHealth Group, Elevance Health, Aetna and Cigna are listed as "co-conspirators"—to set out-of-network prices using a common collective data set and methodology, as opposed to competing with each other individually.</p>
<p>In their lawsuits, providers likened the agreements with codefendant insurers such as UnitedHealth Group, Elevance Health, Aetna and Cigna to a collusive “cartel,” arguing that they share confidential information to suppress rates. The company has countered that its reimbursement recommendation product uses common, publicly available data sources, not competitor data, when making its recommendations to managed care organizations and third-party administrators.<br> </p>
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<td><a href="https://www.fiercehealthcare.com/sponsored/overcoming-pharmacy-distractions-hinder-patient-care" style="font-family:Helvetica, sans-serif; letter-spacing:-1px;margin:0;padding:0 0 2px;font-weight: bold;font-size: 19px;line-height: 20px;color:#222;">Overcoming Pharmacy Distractions that Hinder Patient Care</a>
<div style="font-family:Helvetica, sans-serif; text-align:left;color:#999;font-size:11px;font-weight:bold;line-height:15px;">Apr 6th 2026, 13:45</div>
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<p><div class="col content" morss_own_score="6.0" morss_score="13.0">
<p morss_own_score="7.0" morss_score="75.0"></p><p>Pharmacists are among the most accessible healthcare providers in the system. Their responsibilities now extend well beyond dispensing to include immunizations, medication management, chronic disease support, and preventive care initiatives. Yet even as clinical expectations expand, much of a pharmacist’s day can still be consumed by operational pain points, limiting time for patient engagement.<br></p><p>In many pharmacies, the workday is defined by constant interruptions – phone calls about prescription status, prior authorizations and insurance issues, and system alerts that require immediate attention. Individually routine, these disruptions combine to create a reactive workflow that pulls pharmacists away from focused clinical care. This has broader consequences, as pharmacy performance directly affects medication adherence, patient satisfaction, and value-based outcomes. When attention is continually divided, both productivity and patient care can suffer.<br><br><strong>The Cognitive Cost of Interruptions</strong><br></p><p>In pharmacy practice where prescription verification, coordinating with payors and prescribers, and patient counseling require sustained concentration, switching tasks introduces unnecessary vulnerability.<br></p><p>Even small inefficiencies accumulate quickly. Minutes lost to system navigation, manual rework, or redundant data entry multiply across hundreds of prescriptions each week. The result is a reduced ability to focus on patient-facing care.<br></p><p>Alert fatigue adds to the challenge. When non-critical warnings crowd verification queues, truly meaningful alerts are easier to miss, weakening safeguards meant to protect patients. These pressures are compounded by broader industry realities, including workforce shortages, growing prescription complexity, expanding clinical expectations, and tighter reimbursement margins.<br></p><p>Pharmacies are being asked to deliver more value with constrained resources. In this environment, protecting pharmacists’ cognitive bandwidth can be important to delivering consistent, high-quality patient care.<br><br><strong>When Technology Fragments Workflows</strong><br></p><p>Technology was intended to streamline pharmacy tasks. However, many organizations still rely on multiple disconnected platforms for dispensing, claims processing, documentation, reporting, and patient communications.<br></p><p>Instead of reducing complexity, siloed systems can amplify it. Each additional log-in, alert, or manual handoff introduces friction. Over time, that friction erodes efficiency, creates unnecessary complexity, and has the potential to impact patient care.<br><br><strong>Optimizing Operations to Improve Patient Care</strong><br></p><p>As a long-standing partner to pharmacies across the U.S., McKesson has a front-row view into how operational complexity shapes the pharmacist experience and, ultimately, patient care.<br></p><p>Addressing these challenges requires more than incremental adjustments. It calls for integrated infrastructure and automation designed to reduce low-value manual tasks while preserving clinical safeguards.<br></p><p>One example of this enterprise-focused approach is EnterpriseRx® from McKesson Pharmacy Systems. Designed as a centralized pharmacy management platform, EnterpriseRx integrates prescription processing, clinical review, reporting, and communication within a unified ecosystem. With over 200 certified third-party integrations, EnterpriseRx delivers configurable workflows designed to meet the unique needs and operational complexities of each pharmacy organization. EnterpriseRx features a single, easy-to-use interface, helping to minimize avoidable interruptions, streamline pharmacy management workflows, and support pharmacists in delivering patient-centered care.<br></p><p>Automation capabilities target common friction points, including repetitive data entry, claim adjudication steps, and routine refill processing. Prioritized alert management seeks to reduce unnecessary system noise while maintaining meaningful clinical oversight. For multi-site organizations, centralized workload management can distribute tasks across locations, easing demand spikes and supporting consistent performance.<br></p><p>From an executive perspective, operational integration may help deliver measurable advantages:</p><ul><li>Simplify operations</li><li>Enhance patient care</li><li>Reduce costs</li><li>Data-driven insights</li></ul><p morss_own_score="7.0" morss_score="19.0"><br><strong>Reestablishing Patient Care as the Top Priority</strong><br></p>
<p>When operational systems work together seamlessly, pharmacists may be better positioned to spend more of their time caring for patients – and McKesson sees that as an essential to strengthening pharmacy’s role in the healthcare system.<br></p><p>While distractions will always be part of pharmacy practice, modernizing infrastructure and reducing workflow fragmentation can help free pharmacists to focus on what matters most – safe, patient-centered care.</p></div></p>
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<td><a href="https://www.fiercehealthcare.com/providers/ambience-healthcare-launches-chart-chat-first-ehr-integrated-ai-copilot-nurses" style="font-family:Helvetica, sans-serif; letter-spacing:-1px;margin:0;padding:0 0 2px;font-weight: bold;font-size: 19px;line-height: 20px;color:#222;">Ambience Healthcare launches AI copilot for nurses</a>
<div style="font-family:Helvetica, sans-serif; text-align:left;color:#999;font-size:11px;font-weight:bold;line-height:15px;">Apr 6th 2026, 13:45</div>
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<p><div class="col content" morss_own_score="5.2250922509225095" morss_score="52.00440025457834">
<p>Ambience Healthcare rolled out Chart Chat for Nursing, touting it as the first electronic health record-integrated artificial intelligence conversational tool for inpatient nurses.</p>
<p>The tool pulls from the EHR to allow nurses to ask questions on patients’ charts, with each response paired with full citations, the company said in a <a href="https://www.businesswire.com/news/home/20260401886689/en/Ambience-Healthcare-Launches-Chart-Chat-for-Nursing-the-First-EHR-Integrated-Conversational-AI-Tool-for-Inpatient-Nursing">press release</a>. Nurses can ask plain-language questions, pulling from physician progress notes, hospital policy, documentation, orders and recent labs in seconds. Executives said the new feature marks the company's first step in its purpose-built nursing roadmap with new capabilities planned in the future.</p>
<p>Cleveland Clinic is the first health system to pilot the program, and will aid Ambience in developing its “purpose-built nursing roadmap," executive said.</p>
<p>To ensure patient safety, Chart Chat responses are controlled by standard deployment evaluations, real-time response quality monitoring and continuous “nurse-in-the-loop” feedback. If the AI tool encounters “ambiguity or insufficient data,” the platform will explicitly tell the nurse.</p>
<p>Ambience Healthcare Head of Product Tanha Kabir told Fierce Healthcare there is no similar AI tool “commercially available to nurses.” </p>
<p>“Most AI tools for nurses today focus on ambient documentation and were originally built for physicians,” Kabir said. “But the nurses on our team and our nursing partners have been very clear: nurses aren't struggling with a lack of information, they're drowning in it.”</p>
<p>A <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC8795724/#:~:text=Despite%20the%20evident%20importance%20of,reports%20%5B16%2C%2017%5D.">January 2022 study</a> published in the National Library of Medicine found nurses in the U.S. can spend between 25% to 41% of their time on documentation. </p>
<p>“We know that nurses can spend a significant portion of their shift in the EHR,” Kabir said. “Reducing that burden has meaningful downstream effects, more time at the bedside, smoother care coordination, and ultimately safer patient care.” </p>
<p>Nurses using the tool say it is “helping them build a richer, more confident understanding” of patients, according to Kabir.</p>
<p>“They have also consistently cited time savings, particularly for complex, long-stay patients where synthesizing the full admission history used to take significant effort,” Kabir said, adding that it has been “especially useful” for handoff prep, care trends and quick answers of specific clinical questions. </p>
<p>“The overall sentiment has been that this is a tool nurses are genuinely excited about and want to use, which is rare in healthcare technology,” Kabir said. </p>
<p>Founded in 2020, Ambience built a platform that uses AI for documentation, clinical documentation integrity and point-of-care coding. The AI documentation software records patient appointments, automates documentation with ambient listening and preps them with specialty-specific chart summaries. In July, the company <a href="https://www.fiercehealthcare.com/health-tech/ambience-banks-243m-series-c-investors-continue-bet-big-ambient-ai">secured $243 million</a> in series C funding, marking one of the largest health tech raises so last year.</p>
<p>The company continues to build out new AI tools and last fall it <a href="https://www.fiercehealthcare.com/ai-and-machine-learning/ambience-launches-ai-powered-icd-10-coding-assistant-inpatient-care">launched</a> an ICD-10 clinical document integrity assistant for inpatient care. At the time, executives noted the company saw big opportunities to support allied health and nursing staff with AI assistive agents.</p>
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<p><strong>Forwarded by:<br />
Michael Reeder LCPC<br />
Baltimore, MD</strong></p>
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