The report’s emphasis on high denial rates for prior authorization requests should serve as a warning, particularly for services like skilled nursing care. OIG underscores the need for facilities to advocate for transparent and consistent utilization review processes, strengthen communication with payers, and meticulously document the need for services, to minimize denials and ensure timely access to necessary care for residents.
Three factors raise concerns that some people enrolled in Medicaid managed care may not be receiving all medically necessary health care services intended to be covered: (1) the high number and rates of denied prior authorization requests, (2) the limited oversight of prior authorization denials in most States, and (3) the limited access to external medical reviews.
Overall, the MCOs included in our review denied one out of every eight requests for the prior authorization of services in 2019. Among the 115 MCOs in our review, 12 had prior authorization denial rates greater than 25 percent—twice the overall rate. Despite the high number of denials, most State Medicaid agencies reported that they did not routinely review the appropriateness of a sample of MCO denials of prior authorization requests, and many did not collect and monitor data on these decisions. The absence of robust oversight of MCO decisions on prior authorization requests presents a limitation that can allow inappropriate denials to go undetected in Medicaid managed care.
FULL REPORT: Department of Health and Human Services, & Grimm, C. A. (2023). High rates of prior authorization denials by some plans and limited state oversight raise concerns about access to care in Medicaid managed care. https://oig.hhs.gov/oei/reports/OEI-09-19-00350.pdf
OIG Summary: High rates of prior authorization denials by some plans and limited state oversight raise concerns about access to care in Medicaid managed care. (2024, February 27). Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. https://oig.hhs.gov/reports/all/2023/high-rates-of-prior-authorization-denials-by-some-plans-and-limited-state-oversight-raise-concerns-about-access-to-care-in-medicaid-managed-care/
KFF’s coverage highlights the OIG’s investigation into Medicaid MCOs’ prior authorization practices, prompted by concerns about potential barriers to care. Key findings include wide variation in denial rates across MCOs, potential for delayed care due to denials, and the need for improved state monitoring.
Saunders, H., & Hinton, E. (2023, July 27). New OIG report examines prior authorization denials in Medicaid MCOs | KFF. KFF. https://www.kff.org/policy-watch/new-oig-report-examines-prior-authorization-denials-in-medicaid-mcos/
Hut, N. (2023, August 1). Concerns about access to care raised by OIG findings on prior authorization policies in Medicaid managed care. HFMA. https://www.hfma.org/payment-reimbursement-and-managed-care/medicaid-payment-and-reimbursement/oig-findings-on-prior-authorization-policies-in-medicaid-managed-care/
Olsen, E. (2023, July 20). Prior authorization denials could limit access in Medicaid managed care, OIG reports. Healthcare Dive. https://www.healthcaredive.com/news/High-rates-prior-authorization-denials-Medicaid-manged-care-OIG-report/688564/
Wyden, Pallone Launch Investigation into Medicaid Managed Care Plan Prior Authorization Practices | The United States Senate Committee on Finance. (2023, October 3). https://www.finance.senate.gov/chairmans-news/wyden-pallone-launch-investigation-into-medicaid-managed-care-plan-prior-authorization-practices
Managed Care Prior Authorization Denials | Myers & Stauffer. (2023, November 27). Myers and Stauffer. https://myersandstauffer.com/managed-care-prior-authorization-denials/
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
