Get Full Government Meeting Transcripts, Videos, & Alerts Forever!
Get email alerts on the Healthcare Admin topic
No spam. Unsubscribe anytime.
Researchers find high prior-authorization denials and recommend single credentialing; Connecticut ASO model offered as a policy option
Summary
Presenters reviewing administrative costs told the committee that prior-authorization denial and processing rates vary widely across payers (20—27% denials widely, Medicaid managed-care denial spikes around 45%). They recommended standardizing forms, boosting OSI oversight and exploring single credentialing and an ASO Medicaid model described from Connecticut.
Researchers presenting to the committee said administrative burdens in New Mexico's health system—prior authorization, credentialing and fragmented insurer processes—contribute meaningfully to provider costs and delays in patient care. They offered data, policy options and an example from Connecticut that moved from an MCO model to Administrative Service Organizations (ASOs).
Preliminary prior-authorization data (2021) showed considerable variation by payer type. Presenters reported denial rates of roughly 20—27% to 27—27% across commercial and marketplace plans, and higher denial rates in some Medicaid managed-care plans (a cited figure of around 45—27% for prior-authorization denials in the Medicaid managed-care category). Specific insurer approval-rate examples were cited: Blue Cross Blue Shield of New Mexico was shown with about an 81—27% approval rate in 2023 data while UnitedHealthcare showed an approval rate nearer 53—27% in the same dataset. Processing times for non-urgent prior-authorizations and urgent requests also varied across insurer types.
Presenters urged consideration of several remedies: a single, standardized prior-authorization form or portal; a single credentialing application for Medicaid MCOs (a repeated committee request); stronger oversight and data collection by the Office of Superintendent of Insurance (OSI) and Health Care Authority; and pilot 'gold-card' programs that let high-performing providers bypass frequent prior-authorization requirements via a centralized process. They flagged concerns about equity if a "gold-card" system favored providers serving wealthier or better-insured populations and recommended equity safeguards.
Dr. Michael Guzmano described Connecticut's earlier transition from capitated MCO contracts to a hybrid, vendor-based ASO model. He said the ASO approach simplified administrative complexity, sped vendor claims payments (paying claims through a vendor within two weeks, per his account), and improved transparency in network participation, although it did not eliminate concerns about low specialist rates and the need for sustainable provider payments.
Committee members asked whether any state has fully removed prior authorization (presenters said not in the U.S.), whether standardized credentialing is feasible, and how to design contracting or procurement provisions to incent insurer cooperation. Researchers recommended convening OSI, HCA, insurers and provider groups to pilot a single credentialing process and to explore contractual levers that the state already holds as a purchaser.
The presenters said their work would continue and that they expect to produce more detailed policy and costing recommendations in future reports.
