Private health insurers paid for by Medicaid denied millions of requests for care from low-income Americans because of little oversight from federal and state officials, according to a new report from US investigators published Wednesday.
Medicaid, the federal-state health insurance program for the poor that covers approximately 87 million Individuals contract with companies to reimburse hospitals and doctors for treatment and to manage a person’s medical care. About three-quarters of people enrolled in Medicaid receive health services through private companies, which are typically paid a fixed amount per patient rather than per procedure or visit.
reports The Office of Inspector General of the US Department of Health and Human Services details how often private insurance plans refused to approve treatment and how states handled the denials.
Doctors and hospitals continually complain about what they perceive to be endless paperwork and unfair denials of care by insurers when they fail to authorize expensive procedures or drugs. Companies that require prior authorization for certain types of medical services say the devices are intended to curb unnecessary or unproven treatments, but doctors Claim This often interferes with ensuring that patients receive the services they need.
The investigators also raised concerns about a payment structure that provides a lump sum per patient. They worried that it would encourage some insurers to maximize their profits by denying access to medical care and services for the poor.
The report emphasized the important role that state and federal officials should play in ensuring that denials were fair. “People of color and low-income people are at increased risk of receiving low-quality health care and experiencing poor health outcomes, which makes it especially important to ensure access to care for Medicaid populations,” the investigators said.
The report found that for-profit insurers operating some Medicaid plans, including Aetna, Eleven’s Health, Molina Healthcare and UnitedHealthcare, denied medical care under prior authorization requests for services at rates greater than 25 percent in 2019. About 2.7 million people were enrolled in these plans at the time. Another 8.4 million were enrolled in plans with higher-than-average rejection rates, ranging from 15 to 25 percent.
According to the report, Molina, based in Long Beach, California, operated seven schemes with a rejection rate of over 25 percent. Its Illinois plan denied 41 percent of requests.
Insurers are “held accountable through extensive oversight” by federal and state governments, Christine Groh, a spokeswoman for industry trade group AHIP (formerly America’s Health Insurance Plans), said in a statement.
The companies named in the inspector general’s report did not immediately respond to requests for comment.
Doctors agree that Medicaid patients can’t wait for the insurer to approve care, let alone reverse its decision. Springfield, Mo. “You don’t always have the opportunity to see a patient, send a prior authorization request, and schedule them back,” said Dr. Matthew Stinson, who works at the Jordan Valley Community Health Center in Washington, D.C., where a large number of Medicaid patients are seen. “It’s an access problem.”
Some of the clinic’s patients will drop out of care, he said. When an insurer denies a pregnant woman an ultrasound, the center may decide to do the test anyway because she may not return. “We didn’t necessarily get paid for that ultrasound,” Dr. Stinson said.
Concerns over improper disclaimers are not limited to Medicaid. Last year, the same investigators examined denials among private Medicare Advantage plans and found that some of the care that was denied may, in fact, have been medically necessary. While the current report did not look at whether Medicaid denials were valid, the investigators emphasized that insurers were more aggressive in refusing to authorize care under Medicaid than under Medicare, the federal program for the elderly and disabled.
He said companies denied one in eight requests in 2019, which is nearly double the rate under Medicare Advantage. Unlike Medicare, if an insurer refuses to authorize treatment, patients are not automatically provided with an outside medical opinion as part of their appeal. They are entitled to a state hearing.
“These differences in access to oversight and external medical reviews between the two programs raise concerns about health equity and access to care for those enrolled in Medicaid managed care,” the investigators said.
Patients also complain that it is difficult to get care under these plans. Bree Moss, 34, who lives in Dubuque, Iowa, has been diagnosed with diabetes since she was 12, but she’s struggled to get her Medicaid plan to approve a new insulin pump her doctor recommended to help control her blood sugar.
“This could be a game changer for me,” said Ms Moss, who said her insurer would not initially cover it. Working with People’s Action, a national advocacy network, and a partner organisation, Iowa Citizens for Community Improvement, where she is a member, Ms Moss eventually won an appeal to cover the device.
Investigators also found that the state’s oversight of coverage disclaimers was lax. Many states do not routinely investigate insurers’ denials nor collect information on how often a plan denies prior authorization requests. They do not ensure that people can get a second medical opinion if they want to appeal. According to the report, the lack of review makes it challenging for federal and state officials to know whether insurers are “meeting their commitments to ensure coverage of medically necessary health care”.
“In the absence of federal requirements, we see these three tools being used inconsistently,” said Rosemary Bartholomew, who helped lead the team that developed the report.
States are directly responsible for overseeing insurance providers of Medicaid coverage. But the investigators urged the need for more oversight from the federal Centers for Medicare and Medicaid Services.
In the report, federal officials did not say whether they agreed with the investigators’ recommendations, and CMS said it planned to review the report’s findings to determine next steps.
The denial rates recorded by the investigators varied widely by insurer and state. The investigators looked at 115 managed care organizations in 37 states operated by the seven multistate insurers with the highest Medicaid enrollment, representing nearly 30 million people in 2019. They requested information on denials from insurers and surveyed states about their oversight role.
Elevens, the for-profit insurer formerly known as Anthem, had plans with rejection rates that ranged from 6 to 34 percent, while UnitedHealthcare had plans that had rates ranging from 7 to 27 percent.
“While any individual prior authorization denial may have been appropriate, it is unclear why some MCOs” or managed care organizations “had much higher rates of prior authorization denial than their peers,” the investigators said.
