Managed Care Organizations and the Improper Denial of Claims to Healthcare Providers in the New York Metropolitan Area

The Capstone team was asked to evaluate the validity of complaints that the client has received from health care providers regarding the improper administration of claims by managed care organizations (MCOs). Providers have alleged that claims are arbitrarily being denied or delayed and that provider appeals of such denials are not being administered in accordance with State mandates. An extensive review of relevant laws that apply to the administration of claims by MCOs was completed. The team narrowed its focus to the legal requirements of the New York State Utilization Review laws that govern the appeals processes between health care providers, enrollees, and payers. Two years of data from several different health care facilities was comprehensively reviewed and analyzed. The initial findings confirm that a number of managed care organizations are in violation of State law. The team ultimately quantified the damages that resulted from the violations.