New York did not ensure that a managed care organization complied with requirements for denying prior authorization requests

New York did not ensure that a managed care organization complied with requirements for denying prior authorization requests

Collection:
Health Policy and Services Research
Contributor(s):
United States. Department of Health and Human Services. Office of Inspector General. Office of Audit Services, issuing body.
Publication:
[Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, September 2023
Language(s):
English
Format:
Text
Subject(s):
Government Regulation
Managed Care Programs -- legislation & jurisprudence
Medicaid -- legislation & jurisprudence
Medicaid -- organization & administration
Prior Authorization -- economics
New York
Genre(s):
Technical Report
Abstract:
Why OIG Did This Audit. OIG has identified longstanding challenges, including insufficient oversight and limited access to specialists, that may reduce the quality of health care services provided to Medicaid enrollees. The Senate Special Committee on Aging requested that OIG conduct a review of the Medicaid managed care organization (MCO) industry to determine whether these companies are meeting their obligations to serve children, older adults, and people with disabilities and their families. In addition, several news articles have highlighted concerns related to the Medicaid managed care program and its oversight. Our objective was to determine whether New York’s oversight of Centers Plan for Healthy Living (CPHL) ensured compliance with Federal and State requirements when CPHL denied access to requested services that required prior authorization. How OIG Did This Audit. Our audit covered denials of prior authorization requests for CPHL long-term care services and dental services that were either overturned by New York or withdrawn by CPHL. For these requests submitted during the period from April 2018 through March 2020, CPHL reported 1,131 overturned denials and 19 withdrawn denials. We reviewed a judgmental sample of 70 denials to determine whether they complied with Federal and State requirements.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (17 pages))
Illustrations:
Illustrations
NLM Unique ID:
9918751187206676 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/9918751187206676