GAO report finds lack of oversight on Medicaid managed care plans’ prior authorization requirements for children

A report released May 29 by the Government Accountability Office found a lack of state oversight on Medicaid managed care plans’ use of prior authorization for children’s health care services. It found that none of the states sampled reviewed a representative sample of commercial Medicaid plans’ claim denials or used data to assess “the appropriateness of the full scope of plans’ prior authorization decisions.” The study underscores concerns that Medicaid managed care plans may implement policies that deny medically necessary care to children enrolled in Medicaid.  
 
The GAO recommended the Centers for Medicare & Medicaid Services communicate expectations for how states should monitor the appropriateness of plans’ prior authorization decisions and confirm that states meet these expectations; and clarify whether managed care plans can require prior authorization for early and periodic screening, diagnostic and treatment services when the state doesn't have such requirements. CMS partially concurred with each recommendation, according to the report.