AHA Knowledge Exchange Managed Medicaid: Ensuring Quality Health Care Delivery 
 
AHA Knowledge Exchange | 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.

Sponsored by: CorroHealth Logo

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

Odette Bolano, FACHE, MHA, BSN

President and CEO

Saint Agnes and Saint Alphonsus

Clara Evans

Clara Evans, MHA

Vice President, Government Affairs

Rady Children’s Hospital–San Diego

Tina Grant

Tina Grant, J.D.

Senior Vice President, Advocacy and Public Policy

Trinity Health

Gerald Grimaldi

Gerald Grimaldi

Chief Health Policy and Government Relations Officer

University Health

Jason Kruse

Jason Kruse, D.O.

Interim CEO

Broadlawns Medical Center

Kenneth Morris Jr.

Kenneth Morris Jr., MHA, MA

Vice President, External Affairs

St. Joseph’s Health

Jerrilyn Morrissey

Jerilyn Morrissey, M.D.

Chief Medical Officer

CorroHealth

Charlton Park

Charlton Park, MBA, MHA

Chief Financial Officer and Chief Analytics Officer

University of Utah Hospital and Clinics

 
Julie Peterson

Julie Petersen, CPA

CEO

Kittitas Valley Healthcare

 
Carly Salamone

Carly Salamone, MPH

Executive Administration and Government Relations Director

Fisher-Titus Health

 
Larry Shackelford

J. Larry Shackelford, CPA, FACMPE

President and CEO

Washington Regional Medical System

Doug Skrzyniarz

Doug Skrzyniarz, MHSA

Vice President, Government Relations

Community Health Systems

Suzanna Hoppszallern

Moderator:

Suzanna Hoppszallern

Senior Editor, Center for Health Innovation

American Hospital Association

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