In the complex landscape of health insurance applications—particularly within regulated programs such as Medicaid and Medicare—certain recurring mistakes often hinder the effectiveness of agents and agencies, especially when working with carriers like Molina Healthcare. These common errors can lead to delays, damage client trust, and result in avoidable application rejections. This blog outlines the most frequent pitfalls, how to recognize them early, and proven strategies to address them before they escalate into major obstacles.
1. Excessive Denials in Prior Authorizations 🛑
What happens:
Molina was identified in 2023 as one of the insurers with the highest denial rates for prior authorizations in Medicaid. In some states, this rate exceeds 25% and reaches 41% in Illinois.
Impact on your work:
- Frustrated clients and loss of trust.
- Increased appeals and use of medical review processes.
- Financial consequences if a necessary service isn’t covered.
How to prevent it:
- Ensure all medical documentation is complete and meets clear clinical criteria.
- Use Molina’s portal to check the status before submitting or resubmitting requests.
- Consider attaching clinical summaries, protocols, or medical notes when possible.
2. Frequent Issues in Agent and Member Portals
What happens:
There are reports of technical glitches on the member portal, such as deactivated buttons after responses, which block proper follow-up.
Impact on your work:
- Delayed resolution of inquiries and requests.
- Clients lose visibility of the process, creating uncertainty.
- Increased workload for broker support teams.
How to prevent it:
- Regularly check the portal and test critical features.
- If issues occur, document the incident with screenshots and send it to the Broker CARE Team.
- Keep proactive communication with the client while technical issues are resolved.
3. Errors in Enrollment Information (CAQH, Licenses, E&O)
What happens:
Delays or rejections in onboarding due to inconsistent data; reports indicate common causes include expired licenses or insufficient Errors and Omissions (E&O) coverage (under $1M).
Impact on your work:
- Portal access deactivated due to lack of state approval.
- Delays of days or weeks to regularize status.
How to prevent it:
- Update licenses and E&O policies in advance (minimum $1M per claim and total).
- Review and certify your CAQH profile.
- After submitting documentation, monitor the status on Molina’s site.
4. Missing Documentation Receipts in Enrollments
What happens:
Cases are reported where Molina enrolls members without written evidence of the application, complicating tracking and resolution.
Impact on your work:
- Clients lack tools to appeal or recertify.
- Disputes arise over charges or coverage without documentation.
How to prevent it:
- Save email confirmations or portal screenshots.
- If enrollment is done by phone, request a confirmation number.
- Follow up immediately through official channels.
5. Negligence in Payments and Billing
What happens:
Clients report that Molina fails to process payments or invoices properly, leading to delayed recognition and billing errors.
Impact on your work:
- Clients receive bills for services already covered.
- Formal complaints and intensive use of the appeals process.
How to prevent it:
- Confirm each payment through the agent portal or call the Broker CARE Team.
- Notify clients of billing cycles and registration times (usually 10 days after the first payment).
- Keep payment records with screenshots or PDFs.
6. Denials Due to Incomplete or Discrepant Documentation
What happens:
Molina denies applications with incorrect data, insufficient documents, or discrepancies between sources.
Impact on your work:
- Denials over technical issues (e.g., different address, outdated license).
- Extra workload in resubmitting information.
How to prevent it:
- Verify that name, date of birth, address, license number, and tax info match across all systems.
- Use updated official documents (licenses, certificates, utility bills, CLIA, etc.).
- Avoid mixing manual and digital formats in one application.
7. Mismanaged Appeals and Grievance Processes
What happens:
Lack of knowledge about appeal deadlines (30, 60, 180 days depending on the type of grievance).
Impact on your work:
- A date error can invalidate an appeal.
- Clients may feel you’re not advocating for them.
How to prevent it:
- Memorize key deadlines:
- 5–10 days for acknowledgment.
- 30–60 days for grievance resolution.
- 180 days for appeals after a Notice of Action (NOA).
- Use unified alerts (CRM or shared calendars).
- For urgent clinical matters, request expedited review.
8. Support Channel Misalignment
What happens:
Molina has multiple lines (Member Services, Broker CARE Team, DHMC, commissions), and not all cases are routed properly.
Impact on your work:
- Request trails are lost or efforts are duplicated.
- Confusion about which channel to use based on issue type.
How to prevent it:
- Document the first contact: date, channel, case number.
- Follow the guide: Broker CARE for billing/enrollment; Member Services for portal/member concerns.
- Escalate to the regulator (DMHC, state DOI) if Molina delays more than 30–60 days.
9. Frozen Statuses from “Known Issues” Without Follow-up
What happens:
Molina lists “Known Issues” on its site but some cases don’t receive personalized tracking. (molinahealthcare.com)
Impact on your work:
- Clients believe their claims are stalled.
- Frustration over feeling neglected.
How to prevent it:
- Periodically check the Known Issues section to see if the problem is listed.
- Explain to the client that Molina is already working on it and share the issue reference.
- Don’t send duplicate claims if the problem is publicly documented.
10. Lack of Persistent Communication
What happens:
Inquiries without immediate follow-up or response, both at agent and agent-client levels.
Impact on your work:
- Damages professional relationships.
- Increases client attrition or negative public feedback.
How to prevent it:
- Set M-M-N (Morning, Midday, Night) updates for each case.
- Use CRM tools for task assignments, alerts, and email reminders.
- Consider implementing internal response-time standards for client peace of mind.
These ten recurring errors highlight key areas where agents and agencies can significantly improve their performance when managing applications with Molina Healthcare. Applying best practices—such as thorough documentation, proactive deadline management, cross-verification of data, and timely follow-up—helps minimize problems, reduce resolution time, and strengthen client satisfaction and trust.
