Medicaid managed care plans may be shortchanging their members on care – or so suggests a new review by the Department of Health and Human Services’ Office of the Inspector General.

According to the OIG, the Medicaid managed care plans it audited in 37 states rejected one out of every eight requests for prior authorization, with more than ten percent of the audited plans denying prior authorization requests more than 25 percent of the time.

Such findings, the OIG concluded, “…raise(s) concerns about health equity and access to care for Medicaid managed care enrollees.”

To address this problem, the OIG recommends that the Centers for Medicare & Medicaid Services

(1) require States to review the appropriateness of a sample of MCO prior authorization denials regularly, (2) require States to collect data on MCO prior authorization decisions, (3) issue guidance to States on the use of MCO prior authorization data for oversight, (4) require States to implement automatic external medical reviews of upheld MCO prior authorization denials, and (5) work with States on actions to identify and address MCOs that may be issuing inappropriate prior authorization denials.

Learn more from the 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” and find a summary of that report here.