The Prior Authorization Desk Needs Prior Authorization

I have reviewed the federal audit, and the document coughed before I did: Health Share of Oregon’s prior-authorization denial process was not consistently meeting the rules that make those denials lawful, timely, understandable, and properly reviewed. The HHS Office of Inspector General examined 100 Medicaid denials and found that 21 failed to comply with at least one federal or state requirement. This is the bureaucratic equivalent of a courthouse discovering its front door requires a permit.

The failures were not confined to one ceremonial checkbox. OIG identified problems involving the expertise used to make decisions, the content of denial notices, the timing of those notices, language access, and communication with providers. In other words, the system responsible for explaining why care was denied sometimes struggled with the basic administrative duties required to explain a denial. Exhibit A had a pulse, and it was asking where Exhibit B went.

OIG estimated that the findings could represent 5,677 noncompliant denials during calendar year 2023. That estimate does not mean every denial was improper, and the audit does not decide whether particular treatments were medically necessary. It identifies something more elemental and, in its own way, more haunting: the gatekeeper enforcing authorization rules did not consistently satisfy the rules governing its own decisions.

The agency issued four recommendations to Health Share of Oregon. Those recommendations are the usual institutional medicine: review procedures, improve oversight, train the machinery, and make sure the paperwork behaves before it is allowed near another human life. Necessary, presumably. But somewhere in the records room, a form is being prepared for the denial department itself.

Therefore, as a matter of administrative justice, the prior-authorization desk should submit its own application for prior authorization. It should demonstrate expertise, deliver a timely and understandable notice, provide language access, and consult the people who actually know what is happening. Until then, patients and providers are being asked to trust a stack of paperwork that the stack could not consistently complete correctly. The filing blinked first.