Move over Medicare Advantage. It turns out that there might be an even more troublesome creature than you. The new problem child? Medicaid managed care organizations (MCOs).

A new investigation by the Office of Inspector General found that in 2019, Medicaid MCOs denied 1 out of 8 (12.5%) prior authorization requests. By way of comparison, that year, MA health plans denied only 5.7% or prior authorization requests.

In this light, MA doesn’t appear so bad, huh? Of course, I am exaggerating. Whatever you think of MA, it’s pretty apparent that it has become an easy target of lawmakers’ and regulators’ ire and disdain. Granted, there is plenty to be concerned about, given the billions that healthcare insurance companies are raking in from MA and the questionable practices that persist. I’m speaking about denials of prior authorization requests and misleading marketing tactics.  

But it appears that Medicaid MCOs may be even more in need of help than MA plans. Most state Medicaid agencies’ oversight of MCO prior authorization denials was limited, the OIG report said. They did not use two key tools — appropriateness reviews for a sample of denials and monitoring MCO denial data — for the monitoring and oversight of prior authorization denials.

By contrast, for MA, the Centers for Medicare & Medicaid Services has implemented both tools in its oversight, according to the report.

“CMS reviews the appropriateness of a sample of prior authorization denials in Medicare Advantage each year as part of its program audits and collects denials and appeals data for each Medicare Advantage plan every year,” the report said.

Score that another point for MA.

There is a lot to delve into in this report. Particularly concerning is that some of those denied care were patients who needed treatment for cancer and cardiac conditions, elderly patients, and patients with disabilities requiring in-home care and medical devices. But as revelatory as the report is for Medicaid MCOs, It also offers some much-needed perspective on MA.

Sometimes it takes an even worse situation to make you see the landscape clearly. MA needs work; it may not be as adrift as we have feared. For that it appears regulators have a new project.

Liza Berger is editor of McKnight’s Home Care. Email her at [email protected].