Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care.

Abstract

To assess patient knowledge of managed care organization (MCO) regulations, availability of alternative ambulatory care, and patient outcome after MCO insurance authorization denial for an emergency department visit. A medical screening examination and a follow-up structured interview were conducted with patients denied authorization for ED visits. The study was conducted at a large urban hospital with 36,000 annual ED visits and 40% MCO patients. During a 7-month period, 151 patients did not receive MCO authorization for ED care. The interview response rate was 75% (104/138) with 13 patients excluded. Eighty-three percent (86/104) of respondents came to the ED because they believed their problem was an emergency. Four percent (4/104) of the respondents had been instructed to go to the ED but were later denied authorization, whereas 85.6% (89/104) did not know that the MCO could deny payment. Only 37% (38/104) of the respondents reported having received instruction on the MCO preauthorization process, whereas of the 19% who contacted their MCO as instructed, all resulted in scheduling difficulties. Although 57% (59/104) received follow-up within 24 hours, 11% (11/104) of the respondents had a subsequent return visit to the ED with a subsequent admission rate of 4% (4/104). Few patients are aware of the need for MCO preauthorization for ED care, and almost half do not receive alternative care within 24 hours. A significant number of patients (11%) returned to the ED with an admission rate of 4%.