The monitoring and oversight in denials and appeals in Medicaid managed care was a core focus of the Medicaid and CHIP Payment and Access Commission's March 15 report to Congress.
MACPAC outlines a series of recommendations to improve the beneficiary experience with the appeals process as well as boost states' monitoring and oversight of denials and appeals:
Five things to know:
1. MACAPAC said Congress should amend the Social Security Act to require that states establish an independent, external medical review process that can be accessed at the beneficiary's convenience. The organization said this would improve trust in the appeals process. Beneficiaries currently appeal few denials.
2. CMS should issue guidance to improve the clarity and content of denial notices.
3. CMS should require Medicaid managed care organizations to provide beneficiaries with the option to receive denials notices electronically.
4. Congress should require states to conduct routine clinical audits of MCO denials and use the findings to ensure access to medically necessary care.
5. CMS should publicly post all state-managed care program annual reports to its website in a standard format to enable analysis. States should be required to include denials and appeals data on their quality rating system websites so beneficiaries can access this information when selecting a health plan.
Read the full report here.