Report: DC MCO Had 20% Prior Auth Denial Rate September 7, 2023

Written by MSDC Staff

In 2019, a DC Managed Care Organization (MCO) denied 20% of prior authorizations submitted, higher than any other state.

A recently published report by the Department of Health and Human Services (HHS) Office of the Inspector General reveals the District government lacks recommended oversight procedures for overseeing prior authorizations in the managed care system. In 2019 - the most recent year for data - that led to very high rates of denials by District MCOs. See the entire report here.

The report comes from Congressional requests to HHS on how MCOs are providing patient care. The OIG reviewed data from the largest MCOs nationally and compared their denial rates nationally and at the state level. For DC, this meant AmeriHealth and Amerigroup were included in the study. The most recent year data was available was 2019.

Nationally, AmeriHealth Caritas had a prior auth denial rate of 6.1%. DC's denial rate was 20%, the highest in any state AmeriHealth served. Anthem, Amerigroup's parent company, had a 12.9% denial rate nationally but "only" a 14.1% denial rate in the District.

Even more disturbing is the lack of documented oversight into this process by the District government. The study looked at three oversight categories:

  • States regularly reviewed prior authorization denials for appropriateness
  • State used denials data for oversight
  • State offered external medical reviews

DC did not meet the criteria for the second or third, and was labelled as "ad hoc" for the first.

This data shows the importance of ensuring all payers, including the MCOs, are included in B25-124, the Prior Authorization Reform Amendment Act. You can help us pass this important legislation by: