A recent review of Medicaid Managed Care Organizations (MCOs) has revealed concerning trends in approving prior authorization requests for services.
In 2019, MCOs denied one out of every eight requests for prior authorization of services, according to a report by the Office of the Inspector General .
The OIG has recommended measures to improve enrollee protections and state oversight of prior authorization denials in Medicaid-managed care in response to these findings. These include:• Mandating States to collect data on MCO prior authorization decisions.• States must implement automatic external medical reviews of upheld MCO prior authorization denials.
“Medicaid is a lifeline for over 80 million people, including children, people with disabilities, seniors, and hardworking families,” he continued. “This report strongly suggests that some private insurance plans, which states have contracted with to provide health care coverage to their residents, may be improperly denying access to critical services to maximize their profits.”
The senator noted that the OIG’s national evaluation of Medicaid MCOs, published in July, examined 115 plans with a minimum of 10,000 enrollees operating across 37 states and managed by seven companies. For example, the report found that, on average, MCOs denied 12.5 percent of requests for prior authorization in 2019, with notable variations from state to state and among different companies and plans.
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