“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 investigators urged the federal Centers for Medicare and Medicaid Services to require more oversight.
In the report, federal officials did not say whether they agreed with the investigators’ recommendations, and C.M.S. said it planned to review the report’s findings to determine any next steps.
The denial rates recorded by the investigators varied widely by insurer and by state. The investigators looked at 115 managed care organizations in 37 states operated by the seven multistate insurers with the highest Medicaid enrollment, representing some 30 million people in 2019. They requested information about denials from the insurers and surveyed the states about their oversight role.
Elevance, the for-profit insurer previously known as Anthem, had plans with denial rates that varied from 6 to 34 percent, while UnitedHealthcare had plans that had rates ranging from 7 to 27 percent.
“Although any individual prior authorization denial may be appropriate, it is unclear why some M.C.O.s,” or managed care organizations, “had rates of prior authorization denials that were so much higher than their peers,” the investigators said.