Lawmakers are launching an investigation into the largest Medicaid managed care organizations over prior authorization denial rates.
On Sept. 28, Sen. Ron Wyden, chair of the Senate Committee on Finance, and Rep. Frank Pallone, ranking member of the House Committee on Energy and Commerce, sent letters to the seven largest Medicaid managed care providers, requesting they submit information on the rate of appeals and denials in their plans, and information on any AI algorithms used in the prior authorization process.
An HHS Office of Inspector General report found the seven largest Medicaid MCO parent companies deny around 1 in 8 prior authorization requests. Of the 115 MCOs the OIG audited, 12 had prior authorization denial rates greater than 25 percent.
"While plans may use prior authorization as a means to manage care, this report raises serious questions about whether plans are improperly using prior authorization to deny care," Mr. Pallone and Mr. Wyden said in a Sept. 28 statement. "This alarming trend cuts across a range of parent companies and makes clear that this is a system-wide problem in need of attention."
Mr. Pallone and Mr. Wyden sent letters to Aetna, AmeriHealth Caritas, CareSource, Centene, Elevance Health, Molina Healthcare and UnitedHealthcare.