One of the insurance contractors for Georgia Medicaid quashed one out of every three orders by doctors for patient care, according to a federal review of data from 2019 that was issued recently. The report, which examined 37 states, also called out Georgia among states that did not report taking some basic oversight steps to ensure denials were reasonable.
That Georgia contractor is known to customers as Amerigroup. It denied 34% of all requests for medical services issued by physicians in 2019, which was the second-highest denial rate among contractors cited in the report. The contractor operates under the parent company Anthem, which has previously been known as Blue Cross and is now called Elevance. In 2019 it served about 380,000 Georgians.
Amerigroup is a “managed care organization” or MCO for Georgia Medicaid recipients. States often contract with insurance companies’ MCOs to administer their Medicaid insurance programs. Medicaid in Georgia is the government insurance program for poor children and some poor adults who are elderly, federally declared disabled, or meet certain work or activity requirements.
Insurance companies usually have lists of services for which they require a prior authorization, where patients and their doctors must ask for approval first to see whether the insurance company agrees the spending is necessary. Insurance companies argue that they are the only check on unreasonably high charges by service providers and whimsical orders by doctors. Doctors argue that insurance companies’ denials have gotten out of hand and clog up important medical care.
Although the state regulates the insurance companies, Georgia did not report taking some basic oversight actions. Georgia was one of only 15 states out of 37 reviewed that did not count the denials its contractors issued in order to see if rates looked unusually high. Georgia was one of only two states that did not respond when asked if it reviewed samples of the denials for appropriateness.
States were not required to do that, but the report’s authors recommended that they do. States are required to monitor appeals of denials, but many denials are never appealed.
The report was issued by the Office of the Inspector General of the U.S. Department of Health and Human Services. Authors of the report expressed concern that if states like Georgia don’t look at the number of denials, no one will.
“That can allow inappropriate denials to go undetected,” they wrote.
Neither Elevance nor the Georgia Department of Community Health, which oversees Medicaid, responded to questions about the Inspector General’s finding before deadline.
It’s a big issue for the health care of patients, doctors say.
Prior authorizations nowadays are not just for unusual procedures or one-off operations. They can even be for medications a patient has taken for years, and the insurance company can change its position on a medication midstream.
“The denials, I mean sometimes we have a patient who’s on a medication for years, and then starts getting denied,” said Dr. Hugo Scornik, a Conyers pediatrician and former head of the Georgia chapter of the American Academy of Pediatrics. “Prior authorizations are a huge deal for primary care practices.”
Among the 115 managed care organizations reviewed nationwide, the average denial rate for prior authorizations was 1 in 8. The report suggested that that was already a high number, even before outliers like Georgia’s.
“Despite the high number of denials, most State Medicaid agencies reported that they did not routinely review the appropriateness of a sample of MCO denials of prior authorization requests, and many did not collect and monitor data on these decisions.”
Two in Georgia had denial rates above the national average. One was under the parent company Elevance, known as Anthem in 2019.
The state of Georgia last year fined Anthem $5 million for what it called a repeated, years-long pattern of violations of policyholder’s rights. Anthem months later changed its name to Elevance.
The other Georgia contractor mentioned among the 2019 data was Wellcare of Georgia, under the parent company Centene, with a denial rate of 16.8%. Both Anthem and Centene still operated Georgia Medicaid managed care organizations in the recent contract year, under the names Amerigroup and Peach State Health Plan.
Credit: HYOSUB SHIN / AJC
Credit: HYOSUB SHIN / AJC
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