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Kansas inspector general audit flags MCO prior authorization delays, inconsistent post‑acute decisions and PBM dispensing fee flows
Summary
Kansas Medicaid Inspector General Steve Anderson told the Bethel committee that recent audits found prior‑authorization delays, inconsistent inpatient/post‑acute level‑of‑care determinations by managed care organizations, and concerning PBM handling of pharmacy dispensing fees.
Kansas Medicaid Inspector General Steve Anderson told the Bethel committee the office’s audits and investigations identified operational problems across managed care organizations and pharmacy benefit managers that affect providers and beneficiaries.
Anderson said a recently published prior‑authorization audit (covering Jan. 1, 2021–Dec. 31, 2023) found significant delays in peer‑to‑peer reviews that sometimes take up to seven business days and, he said, can “result[] in delays to critical care.” High denial rates force hospitals to perform additional peer‑to‑peer reviews and hire staff to manage denials.
The audit also identified a pattern of managed‑care organizations defaulting beneficiaries to observation status rather than inpatient classification. Anderson told…
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