High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care

Date Issued

Monday, July 17, 2023

Submitting OIG

Department of Health & Human Services OIG

Other Participating OIGs

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Components

Centers for Medicare and Medicaid Services

Report Number

OEI-09-19-00350

Report Type

Inspection / Evaluation

Number of Recommendations

Questioned Costs

Funds for Better Use

Open Recommendations

This report has 5 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
23-E-09-029.05	No	$0	$0
CMS should Work with States on actions to identify and address MCOs that may be issuing inappropriate prior authorization denials.
23-E-09-029.03	No	$0	$0
CMS should Issue guidance to States on the use of MCO prior authorization data for oversight.
23-E-09-029.01	No	$0	$0
CMS should Require States to review the appropriateness of a sample of MCO prior authorization denials regularly.
23-E-09-029.04	No	$0	$0
CMS should Require States to implement automatic external medical reviews of upheld MCO prior authorization denials.
23-E-09-029.02	No	$0	$0
CMS should Require States to collect data on MCO prior authorization decisions.