Private health insurance companies paid by Medicaid have denied millions of requests for care for low-income Americans with little oversight from federal and state authorities, according to a new report by U.S. researchers released Wednesday.
Medicaid, the federal-state health insurance program for the poor, which covers almost 87 million people, contracts with companies to reimburse hospitals and doctors for treatment and manage an individual’s medical care. About three-quarters of people enrolled in Medicaid receive health care services through private companies, which are usually paid a fixed amount per patient rather than for each procedure or visit.
The a report from the U.S. Department of Health and Human Services’ office of inspector general details how often private insurance plans refused to approve treatment and how states handled the denials.
Doctors and hospitals have increasingly complained about what they consider endless paperwork and unjustified denials of care by insurers when they do not authorize expensive procedures or drugs. The companies that require prior authorization for certain types of medical services say these tools are intended to curb unnecessary or unproven treatments, but doctors to claim it often gets in the way of making sure patients get the services they need.
The investigators also raised concerns about the payment structure, which provides lump sums per patient. They worried that it would encourage some insurers to maximize their profits by denying medical care and access to services for the poor.
The report emphasized the crucial role that state and federal officials should play in ensuring that the denials are justified. “People of color and people with lower incomes are at greater risk of receiving low-quality health care and experiencing poor health outcomes, which makes ensuring access to care particularly critical for the Medicaid population,” the researchers said.
The for-profit insurance companies, including Aetna, Elevance Health, Molina Healthcare and UnitedHealthcare, operated some Medicaid plans that denied medical care under requests for prior authorization of services at rates that were greater than 25 percent in 2019, the report found. About 2.7 million people were enrolled in these plans at the time. Another 8.4 million were enrolled in plans with above-average denial rates of 15 to 25 percent.
According to the report, Molina, based in Long Beach, Calif., operated seven plans with denial rates of more than 25 percent. Its Illinois plan denied 41 percent of requests.
Kristine Grow, spokeswoman for AHIP, (formerly America’s Health Insurance Plans), an industry trade group, said in a statement that insurers “are held accountable by extensive oversight” by the federal and state governments.
The companies named in the inspector general’s report did not immediately respond to requests for comment.
Doctors agree that Medicaid patients may not expect the insurer to approve the care, much less reverse its decision. “You don’t always have the opportunity to see a patient, submit a prior authorization request and schedule them back,” said Dr. Matthew Stinson, who works at the Jordan Valley Community Health Center in Springfield, Mo., who sees. large number of Medicaid patients. “It’s a problem of access.”
Some of the clinic’s patients will skip care, he said. When an insurer denies an ultrasound for a pregnant woman, the center may decide to do the test anyway because she may not return. “We don’t necessarily get paid for that ultrasound,” Dr. Stinson said.
The concern about inappropriate denials is not limited to Medicaid. Last year, the same researchers examined denials among private Medicare Advantage plans and found that some of the denied care may actually have been medically necessary. While the current report did not look at whether the Medicaid denials were valid, the investigators emphasized that the insurers were much more aggressive in refusing to authorize care under Medicaid than under Medicare, the federal program for the elderly and disabled.
They said the companies denied one in eight requests in 2019, roughly 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 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,” the researchers said.
Patients also complain that it is difficult to get care under these plans. Bri Moss, 34, of Dubuque, Iowa, has been diagnosed with diabetes since she was 12, but struggled to get her Medicaid plan to approve a new doctor-recommended insulin pump to help control her blood sugar.
“It could be a game changer for me,” said Ms. Moss, who added that her insurer initially would not cover it. Working with People’s Action, a national advocacy network, and a sister organization, Iowa Citizens for Community Improvement, where she is a member, Ms. Moss eventually won an appeal to cover the device.
The investigators also found that state oversight of coverage denials was lax. Many states do not routinely examine insurer denials or collect information on how many times a plan denies requests for prior authorization. They do not ensure that people can get another medical opinion if they want to appeal. The lack of auditing makes it challenging for federal and state officials to know whether insurers are “meeting their obligations to ensure coverage of medically necessary health care,” according to the report.
“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 supervising insurance providers of Medicaid coverage. But researchers have urged the federal Centers for Medicare and Medicaid Services to call for more oversight.
In the report, federal officials did not say whether they agreed with the researchers’ recommendations, and CMS said it plans 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 about 30 million people in 2019. They requested information about the insurers’ denials and surveyed the states about their oversight role.
Elevance, the for-profit insurer formerly known as Anthem, had plans with denial rates that ranged from 6 to 34 percent, while UnitedHealthcare had plans that had rates from 7 to 27 percent.
“Although any individual prior authorization denial may be appropriate, it is unclear why some MCOs,” or managed care organizations, “had rates of prior authorization denials that were much higher than their peers,” the researchers said.