Healthcare Finance reports on new Office of Inspector General findings regarding high prior authorization denial rates in Medicaid managed care as well as a high likelihood that some people with Medicaid are not getting the care they need. The OIG urges the Centers for Medicare and Medicaid Services (CMS) to do more to ensure that the insurance companies offering managed care to people with Medicaid are honoring their obligations to cover needed care, rather than putting profits first by denying care inappropriately.
The Office of the Inspector General is concerned that people with Medicaid are not getting needed care that corporate insurers should be covering. Moreover, there is little oversight of these corporate insurers. The Centers for Medicare and Medicaid Services and state insurance departments only conduct limited oversight of the insurance companies’ denials. And, people with Medicaid have restricted access to reviews of their denials. Even in Medicare Advantage, CMS oversight is extremely limited; CMS allows health insurers to deny care wrongly with near impunity.
Medicaid insurance companies denied about 12 percent of prior authorization requests or about one in eight of them on average. But, ten percent of the managed care plans that the OIG reviewed denied one in four or more requests for prior authorization. People with Medicaid should know which plans have these high denial rates so they can avoid enrolling in them.
The OIG fears that oversight bodies are not on top of many inappropriate denials of care. So, inappropriate denials continue because they are not addressed.
In addition, the Medicaid appeals process in most states does not offer people the opportunity for an independent review of denials. So, the appeals process is not a check on most insurance companies offering Medicaid. People do have the right to fair hearings in their state, but the process can be challenging for people with Medicaid. Appealing to the Medicaid health plan directly is also not common.
The OIG claims that the system is better for people in Medicare plans operated by insurance companies. That may be true, but the differences do not lead to particularly good outcomes for people with Medicare in these corporate managed care plans. The Centers for Medicare and Medicaid Services does little to hold Medicare Advantage plans accountable for their bad acts, even if these plans must report data on denials and appeals.
If CMS reviews the appropriateness of Medicare Advantage prior authorization denials each year, it should report its findings. People should not be forced to choose a Medicare Advantage plan without knowing the risks that they will be denied care inappropriately if they enroll.
Prior authorizations can be harmful to people’s health, often delaying critical care needlessly. More than nine in ten physicians report these delays. And one in three physicians say that prior authorization leads to serious harm to patients they care for. Nine percent of them say prior authorization leads to “permanent bodily damage, disability or death.”
Here’s more from Just Care:
- Be a Hero tells Congress to end Medicare Advantage wrongful delays and denials of care
- Medicare Advantage enrollees face higher likelihood of hospital care denials
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Traditional Medicare v. Medicare Advantage? Different as night and day
- Proposed new prior authorization rules unlikely to improve access to care for people in Medicare Advantage
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