PALLONE AND WYDEN LAUNCH INVESTIGATION INTO MEDICAID MANAGED CARE PLAN PRIOR AUTHORIZATION PRACTICES

Letter

"While plans may use prior authorization as a means to manage care, this report raises serious questions about whether plans are improperly using prior authorization to deny care. This alarming trend cuts across a range of parent companies and makes clear that this is a system-wide problem in need of attention. Building on this report, we are writing to request additional information regarding your use of prior authorization in Medicaid managed care.

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These findings raise serious concerns that Medicaid MCOs are systematically and improperly denying necessary care which they are required by law to provide. Low-income children and families, seniors, and people with disabilities rely on these plans for access to critical health care services, and prior authorization denials prevent them from receiving these services, which can lead to worse health outcomes.

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Under this arrangement, however, it is critical that MCOs are not improperly denying access to care in an effort to maximize profits given that they are obligated by statute, regulation, and contracts with states to pay network providers for furnishing covered services to enrollees. MCOs should not be prioritizing corporate or shareholder profits ahead of the health and well-being of American families."

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