April 17, 2023

Denials and Appeals at MACPAC

On April 14, Medicaid and CHIP Payment Access Commission (MACPAC) Commissioners and attendees heard a presentation from MACPAC staff on interview findings of beneficiaries and managed care organizations (MCOs). MACPAC serves as a non-partisan advisory and analytic agency to Congress and members of the president’s administration. The questions were designed to help interviewers better understand how appeals processes help beneficiaries access services and understanding of denials oversight in managed care.

MCOs asserted that many denials were issued because of inadequate documentation to determine medical necessity. Beneficiaries noted concerns with conflicts of interest in MCOs handling of appeals citing misaligned incentives.

Following the presentation from staff, spirited conversation and comments from commissioners aligned with many of LeadingAge’s concerns around prior authorization and denials as outlined in this LeadingAge article about our recently issued white paper, Fulfilling the Promise: Medicare Advantage. MACPAC is considering recommendations and LeadingAge will continue to monitor and engage on developments.