Managed Medicaid: Ensuring Quality Health Care Delivery
Managed Medicaid: Ensuring Quality Health Care Delivery
AHA Knowledge Exchange
Data-driven strategies to combat MCO denial tactics
Medicaid Managed care enrollment continues to grow, and some Medicaid managed care organizations (MCOs) are limiting access to quality health care for Medicaid enrollees. MCOs play an important role in ensuring that people with Medicaid coverage have access to medically necessary, covered services. The high number and rate of prior authorization delays and denials of care by some MCOs, the limited state oversight of Medicaid MCOs and the limited access to external medical reviews were concerns raised in the July 2023 Department of Health and Human Services Office of Inspector General report. This Knowledge Exchange explores data-driven strategies to require more transparency and timeliness from payers for Medicaid enrollees to avoid dangerous delays in patient treatment and clinician burnout.
9 ways health systems can combat MCO denial tactics
- Use all dispute mechanisms available in your state and, to the extent that existing framework is insufficient, work with hospitals and hospital associations to pursue stronger regulatory protections.
- Support clinical staff engagement with Medicaid agency advisory groups.
- Create public reporting around Medicaid plan performance, e.g., a payer scorecard or annual report that includes data on payment timeliness, denials, appeals, or other accounts receivable trends.
- Start with due diligence internally and review contracts, data and denials at joint operating committee meetings and escalate cases.
- Document first-level denials, appeals, and activity related to prior authorization, including peer-to-peer reviews to gain the support of state Medicaid agencies, legislators, and other government officials.
- Take egregious Medicaid managed care denials to a state fair hearing and push back on upsurges in blanket denials.
- Encourage the state government to pursue health plan accountability, including payer reporting on denials, appeals, peer-to-peer use, and delays in care.
- Provide feedback on your experience with Medicaid plans to state Medicaid officials who are engaged in the MCO procurement process, including inadequate reimbursement, and plan policies and practices that may compromise beneficiary’s access to care.
- Examine whether alternative arrangements, such as direct-to-employer contracting or starting a provider-led health plan, might be a good fit for your organization’s strategic goals to improve health outcomes and reduce cost.
Participants
Odette Bolano, FACHE, MHA, BSN
President and CEO
Saint Agnes and Saint Alphonsus
Clara Evans, MHA
Vice President, Government Affairs
Rady Children’s Hospital–San Diego
Tina Grant, J.D.
Senior Vice President, Advocacy and Public Policy
Trinity Health
Gerald Grimaldi
Chief Health Policy and Government Relations Officer
University Health
Jason Kruse, D.O.
Interim CEO
Broadlawns Medical Center
Kenneth Morris Jr., MHA, MA
Vice President, External Affairs
St. Joseph’s Health
Jerilyn Morrissey, M.D.
Chief Medical Officer
CorroHealth
Charlton Park, MBA, MHA
Chief Financial Officer and Chief Analytics Officer
University of Utah Hospital and Clinics
Julie Petersen, CPA
CEO
Kittitas Valley Healthcare
Carly Salamone, MPH
Executive Administration and Government Relations Director
Fisher-Titus Health
J. Larry Shackelford, CPA, FACMPE
President and CEO
Washington Regional Medical System
Doug Skrzyniarz, MHSA
Vice President, Government Relations
Community Health Systems
Moderator
Suzanna Hoppszallern
Senior Editor, Center for Health Innovation
American Hospital Association
AHA Knowledge Exchange
Gain insights from the C-suite and health care leaders on the most pressing issues and transformational strategies.
Latest Knowledge Exchange
