Medicaid Controlled Care Organizations (MCOs) denied one out of 8 prior authorization requests in 2019, in step with a brand new document from the Place of business of Inspector Common (OIG).

The OIG assessment incorporated seven MCO mum or dad corporations that operated 115 MCOs throughout 37 states and lined 29.8 million other folks in 2019. The group gained a congressional request to check MCOs and their prior authorization practices.

“Medicaid controlled care organizations play an more and more vital position in making sure that folks with Medicaid have get entry to to medically important, lined services and products,” the OIG mentioned. “In recent times, allegations have surfaced that some MCOs inappropriately behind schedule or denied deal with hundreds of other folks enrolled in Medicaid, together with sufferers who wanted remedy for most cancers and cardiac stipulations, aged sufferers, and sufferers with disabilities who wanted in-home care and clinical units.”

The OIG’s assessment discovered that of the 115 MCOs it analyzed, 12 had prior authorization denial charges above 25%. 

The group additionally found out maximum state Medicaid businesses don’t “robotically assessment the appropriateness of a pattern of MCO denials of prior authorization requests, and lots of didn’t gather and track knowledge on those selections.”

“The absence of sturdy oversight of MCO selections on prior authorization requests items a limitation that may permit beside the point denials to move undetected in Medicaid controlled care,” The OIG mentioned.

Whilst sufferers and suppliers can post an enchantment for prior authorization denials, there are a number of demanding situations, in step with the OIG. For instance, maximum state Medicaid businesses don’t have some way for sufferers and suppliers to ship a denial to an exterior clinical reviewer who can read about if the denial was once improper. As well as, administrative hearings for appeals can “be tricky to navigate and burdensome on Medicaid sufferers,” the document mentioned. Just a small collection of prior authorization denials have been appealed by way of Medicaid enrollees.

The OIG found out that there’s higher CMS oversight of prior authorization denials by way of Medicare Merit plans. For instance, CMS opinions a pattern of denials each and every yr, and Medicare Merit plans are required to supply knowledge on their denials and appeals. Medicare Merit beneficiaries even have get entry to to automated and exterior clinical opinions.

“Those variations in oversight and get entry to to exterior clinical opinions between the 2 systems carry issues about well being fairness and get entry to to deal with Medicaid controlled care enrollees,” the OIG mentioned.

To unravel those problems, the OIG made 5 suggestions to CMS:

• States must be required to check the “appropriateness” of a pattern of MCO prior authorization denials regularly.
• States must be required to assemble knowledge on MCO prior authorizations.
• CMS must supply steerage to states “on using MCO prior authorization knowledge for oversight.”
• States must be required to supply automated exterior clinical opinions of prior authorization denials.
• CMS must paintings with states “on movements to spot and cope with MCOs that can be issuing beside the point prior authorization denials.”

The OIG mentioned that CMS agreed at the ultimate advice, however “didn’t point out whether or not it concurred with the primary 4 suggestions.”

Picture: Piotrekswat, Getty Pictures