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Series: Medicaid Managed Care Organizations' Denials

Announced on  | Last Modified on  | Series Number: W-00-24-31535
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

The State Medicaid agency and the Federal Government are responsible for the financial risk for the costs of Medicaid services. State Medicaid agencies contract with managed care organizations (MCOs) to ensure that beneficiaries receive covered Medicaid services. The contractual arrangement shifts the financial risk from the State Medicaid agency and the Federal Government to MCOs, which can create an incentive for MCOs to deny beneficiaries' access to covered services. Our audits will determine whether Medicaid MCOs complied with Federal requirements when denying access to requested medical and dental services, behavioral health services, and associated drug prescriptions that required prior authorization.

There are 4 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (3)

Project A-03-24-00204 • Announced on Feb 20, 2024

Project A-09-24-02007 • Announced on Aug 19, 2024

Project OAS-25-07-039 • Announced on Feb 5, 2025

COMPLETED PROJECTS IN THIS SERIES (1)

Review of Behavioral Health MCO Denials in Louisiana

Project A-06-24-02000 • Completed on March 30, 2026

TIMELINE

  • February 8, 2024
    Series Number W-00-24-31535 Assigned
  • February 8, 2024
    Project Announced

    Review of Behavioral Health MCO Denials in Louisiana - A-06-24-02000

  • February 20, 2024
    Project Announced

    Project A-03-24-00204

  • August 19, 2024
    Project Announced

    Project A-09-24-02007

  • February 5, 2025
    Project Announced

    Project OAS-25-07-039

  • March 30, 2026
    Project Complete - A-06-24-02000

    Review of Behavioral Health MCO Denials in Louisiana complete. Report Published

  • Today
    3 Projects In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

1 REPORT PUBLISHED

Louisiana Healthcare Connections Generally Complied With Federal and State Process Requirements When Denying Prior Authorization Requests (A-06-24-02000)

LHCC complied with Federal and State requirements when it denied 64 of the 76 sampled behavioral health service requests that required a prior authorization. However, the remaining 12 denied service requests did not meet the administrative or procedural requirements. Specifically, LHCC did not:

  • Provide written notices of adverse determinations (11 prior authorization denials)
  • Provide written notice of adverse determination within the specified timeframe (1 prior authorization denial)

Based on the sample results, we estimated that 3,209 prior authorization denials for behavioral health service requests during our audit period (15.8 percent) did not comply with Federal and State requirements.

Recommendations are updated each month and may not immediately be available for recently completed projects.
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Managed Care
Target Groups
-
Financial Groups
Medicaid