07/31/2023

OIG Report Puts Spotlight on Prior Authorization Denials and Limited Reviews Under Medicaid MCOs 

Source: AAHomecare Insider 7/26/23  

A new report from the HHS Office of Inspector General (OIG) puts a spotlight on potential access issues for patients served by Medicaid Managed Care Organizations (MCOs). The report cites three main factors that may be preventing medically necessary care: (1) the high number and rates of denied prior authorization requests, (2) limited oversight of prior authorization denials in most states, and (3) limited access to external medical reviews.

Overall, the MCOs included in the OIG's review denied one out of every eight requests for the prior authorization of services in 2019. Denials were particularly high with some MCOs: among 115 MCOs reviewed, 12 had prior authorization denial rates greater than 25%; twice the overall rate.

See AAHomecare’s summary of the OIG report, which includes recommendations the OIG shared with CMS on these issues, and the full OIG report High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care for additional details. 

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This new report was a topic during last week's AAHomecare State Leaders Council call held bi-weekly with HME state associations' leadership across the country.  We'll share updates as we receive further analysis from AAHomecare on the OIG’s report that may be appropriate for discussions locally with state Medicaid MCOs.