Medicaid Managed Care Organizations (MCOs) denied one out of eight prior authorization requests in 2019, in response to a brand new report from the Workplace of Inspector Basic (OIG).
The OIG evaluation included seven MCO mother or father corporations that operated 115 MCOs throughout 37 states and coated 29.8 million folks in 2019. The group obtained a congressional request to evaluation MCOs and their prior authorization practices.
“Medicaid managed care organizations play an more and more vital position in making certain that individuals with Medicaid have entry to medically needed, coated providers,” the OIG acknowledged. “In recent times, allegations have surfaced that some MCOs inappropriately delayed or denied take care of 1000’s of individuals enrolled in Medicaid, together with sufferers who wanted therapy for most cancers and cardiac circumstances, aged sufferers, and sufferers with disabilities who wanted in-home care and medical gadgets.”
The OIG’s evaluation discovered that of the 115 MCOs it analyzed, 12 had prior authorization denial charges above 25%.
The group additionally found most state Medicaid businesses don’t “routinely evaluation the appropriateness of a pattern of MCO denials of prior authorization requests, and lots of didn’t gather and monitor knowledge on these choices.”
“The absence of strong oversight of MCO choices on prior authorization requests presents a limitation that may permit inappropriate denials to go undetected in Medicaid managed care,” The OIG mentioned.
Whereas sufferers and suppliers can submit an attraction for prior authorization denials, there are a number of challenges, in response to the OIG. For instance, most state Medicaid businesses don’t have a approach for sufferers and suppliers to ship a denial to an exterior medical reviewer who can look at if the denial was incorrect. As well as, administrative hearings for appeals can “be tough to navigate and burdensome on Medicaid sufferers,” the report mentioned. Solely a small variety of prior authorization denials had been appealed by Medicaid enrollees.
The OIG found that there’s higher CMS oversight of prior authorization denials by Medicare Benefit plans. For instance, CMS critiques a pattern of denials annually, and Medicare Benefit plans are required to supply knowledge on their denials and appeals. Medicare Benefit beneficiaries even have entry to automated and exterior medical critiques.
“These variations in oversight and entry to exterior medical critiques between the 2 applications increase issues about well being fairness and entry to take care of Medicaid managed care enrollees,” the OIG acknowledged.
To resolve these points, the OIG made 5 suggestions to CMS:
- States ought to be required to evaluation the “appropriateness” of a pattern of MCO prior authorization denials regularly.
- States ought to be required to gather knowledge on MCO prior authorizations.
- CMS ought to present steerage to states “on using MCO prior authorization knowledge for oversight.”
- States ought to be required to supply automated exterior medical critiques of prior authorization denials.
- CMS ought to work with states “on actions to determine and deal with MCOs which may be issuing inappropriate prior authorization denials.”
The OIG mentioned that CMS agreed on the final suggestion, however “didn’t point out whether or not it concurred with the primary 4 suggestions.”
Picture: Piotrekswat, Getty Photographs
