U.S. Consultant Frank Pallone, Jr. (D-New Jersey), Power and Commerce Committee rating member, introduced Thursday that he’s investigating the “excessive charges” of prior authorization denials by Medicaid managed care well being plans.
Prior authorization is an insurance coverage follow that requires sufferers to obtain approval for some healthcare companies earlier than they obtain the care. The follow is usually blamed for inflicting delays in affected person care.
The investigation is in response to a current report by the Workplace of Inspector Common that discovered Medicaid Managed Care Organizations (MCOs) denied 12.5% of prior authorization requests (or one out of eight) in 2019. In the meantime, the Medicare Benefit prior authorization denial charge was 5.7% in 2019. The OIG report analyzed seven MCO mother or father corporations that operated 115 MCOs throughout 37 states and lined almost 30 million individuals in 2019.
“I’m deeply troubled by stories that Medicaid managed care plans denied a median of 1 out of each eight requests for therapy, greater than double the speed of service denials in Medicare Benefit,” Pallone stated in a press release.
“Medicaid is a lifeline for over 80 million individuals, together with youngsters, individuals with disabilities, seniors, and hardworking households,” he continued. “This report strongly means that some personal insurance coverage, which states have contracted with to supply well being care protection to their residents, could also be improperly denying entry to essential companies as a way to maximize their income.”
Pallone added that the Medicaid MCOs have to be held accountable for these excessive prior authorization denial charges.
“I applaud the Workplace of the Inspector Common for his or her essential work on this report and for shining a lightweight on these alarming practices,” he stated. “I will probably be contacting every of those medical insurance corporations instantly for added info and questions concerning their prior authorization practices. It’s important that these state contracted plans are upholding their duty to sufferers and their households.”
The OIG evaluation discovered that of the 115 MCOs it seemed into, 12 of them had prior authorization denial charges above 25%. As well as, most state Medicaid companies didn’t commonly assessment the “appropriateness” of denials, nor did they gather knowledge on the denials, the report found.
“The absence of strong oversight of MCO selections on prior authorization requests presents a limitation that may permit inappropriate denials to go undetected in Medicaid managed care,” The OIG stated.
The OIG additionally discovered that Medicare Benefit plans have higher CMS oversight of prior authorization denials than Medicaid MCOs, together with requiring Medicare Benefit plans to supply knowledge on their denials.
The company made a number of suggestions to CMS, together with requiring states to assessment a pattern of MCO prior authorization denials regularly, in addition to mandating states to gather knowledge on MCO prior authorization denials.
Picture: Valerii Evlakhov, Getty Photographs
