Medicaid Managed Care Organizations and Their Role
Medicaid managed care organizations (MCOs) serve approximately 75% of all Medicaid beneficiaries across the United States. These organizations frequently require prior approval for specific healthcare services or medications before they are provided, a process known as prior authorization.
Purpose of Prior Authorization
This step enables MCOs to assess whether the requested care is covered, medically necessary, and appropriate for the patient's needs.
Potential Challenges and Concerns
When an MCO determines that a service or medication does not meet these criteria, it may deny the request either entirely or in part. However, concerns have been voiced by providers and patients about the potential for these prior authorization procedures to cause delays or restrict access to essential care.
Recent Findings
A 2023 report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General highlights ongoing issues related to these policies.