Molina Healthcare has highest denial rate for Medicaid recipients, report says.

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Molina Healthcare has highest denial rate for Medicaid recipients, report says. investigators released Wednesday, and Long Beach – based Molina Healthcare is at the top of the report’s list. Molina Healthcare

After looking into 115 MCOs nationwide, the report from the inspector general’s office of the U.S.

“The absence of robust oversight of MCO decisions on prior authorization requests presents a limitation that can allow inappropriate denials to go undetected,” investigators noted in the report, adding that the appeals process intended to remedy this is deeply flawed and seldom used.

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Investigators identified the seven MCO parent companies with the largest number of enrollees—Aetna Inc., AmeriHealth Caritas, Anthem Inc. (now Elevance Health), CareSource, Centene Corporation, Molina and UnitedHealthcare. These companies operated 115 MCOs in 37 states with a total of 29.8 million people enrolled in 2019.

The other three companies had none.

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At 41.4%, Molina’s Illinois plan had, by far, the single-highest denial rate on the list. Molina’s Texas plan had the second highest rate at 34.2%, followed by Anthem’s Georgia plan at 33.7%.

“The 2019 data on MCO treatment denial rates cited in … [the] report was inclusive of simple procedural denials in which there is a request for additional information that is promptly resolved within applicable deadlines,” the emailed statement said. “Regardless, Molina is continuously working to improve our processes and create the best possible experience for members and providers.”

“These differences in oversight and access to external medical reviews between the two programs raise concerns about health equity and access to care for Medicaid managed care enrollees,” investigators said.

The report recommends the U.S. Centers for Medicare & Medicaid Services (CMS):

Require states to regularly review a sample of prior authorization denials;
Require states to collect data on MCO prior authorization decisions;
Issue guidance to states on the use of said data;
Require states to implement automatic external medical reviews regarding prior authorizations denials; and
Work with states on actions to identify and address MCOs that may be issuing inappropriate denials.

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