VITALS
Out of necessity TennCare’s claims denial process is far stricter than the national average BY KARA HARTNETT
ince the inception of Tennessee’s managed Medicaid program in 1994, state officials have been attempting to balance cost with health care services for the state’s most vulnerable and sickest population. Through waivers and health care reform, the state’s safety-net insurance program has evolved widely over the years, but the basics remain the same: Tennessee pays commercial insurers and other care management organizations on a per-capita basis to manage Medicaid beneficiaries’ health care while attempting to drive down spending and costs.
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FALL 2021 | NASHVILLEPOST.COM
Representative of the evolution of those competing interests may be TennCare’s medical service appeals system, whose outcomes today almost always favor the state and its managed care organizations. The care prescribed by the doctor of a TennCare beneficiary is subject to review by the paying organization, which can deny a claim it believes is unnecessary or has a cheaper alternative. The State of Tennessee does not publish data on the number of claims that are denied to beneficiaries by each managed care organization per year and officials declined to discuss details of TennCare’s policies and claims process. But an internal appeals process captures a tiny percentage of patients and doctors who
petition TennCare to reconsider — often for services such as home health or major procedures the primary care physicians see as medically necessary for their patients. In 2020, of the 8,338 enrollees who appealed the decision of their managed care organization to deny them medical services prescribed by their physicians, 3,006 were resolved by a fair hearing. Of those who got a hearing before the contractor hired by the state, only 145 — less than 5 percent — were able to overturn the original denial. According to the National Association of Insurance Commissioners, the average rate that internal appeals are overturned across all health insurers was 34.2 percent in 2019.
