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Where To Report Waste Fraud, Abuse, Or Retaliation

High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care

Submitting OIG: 
Department of Health & Human Services OIG
Date Issued: 
Monday, July 17, 2023
Agency Reviewed / Investigated: 
Department of Health & Human Services
Submitting OIG-Specific Report Number: 
OEI-09-19-00350
Component, if applicable: 
Centers for Medicare & Medicaid Services
Centers for Medicare and Medicaid Services
Location(s): 
United States
Type of Report: 
Inspection / Evaluation
Questioned Costs: 
$0
Funds for Better Use: 
$0
Number of Recommendations: 
5
Report updated under NDAA 5274: 
No
View Document: 
AttachmentSize
PDF icon OEI-09-19-00350.pdf2.09 MB

Related Open Recommendations

Recommendation Number Recommendation Status Significant Recommendation Additional Details
23-E-09-029.01 Open No
CMS should Require States to review the appropriateness of a sample of MCO prior authorization denials regularly.
23-E-09-029.02 Open No
CMS should Require States to collect data on MCO prior authorization decisions.
23-E-09-029.03 Open No
CMS should Issue guidance to States on the use of MCO prior authorization data for oversight.
23-E-09-029.04 Open No
CMS should Require States to implement automatic external medical reviews of upheld MCO prior authorization denials.
23-E-09-029.05 Open No
CMS should Work with States on actions to identify and address MCOs that may be issuing inappropriate prior authorization denials.
Displaying 5 of 5 Recommendations