Should I Stay, or Should I Go? Provider Considerations for Leaving Medicaid Managed Care Organizations

ABSTRACT

Objective: As states transition from fee-for-service to Medicaid managed care, provider participation is critical for continuity of care. This study examines the factors influencing provider decisions to exit or consider exiting Medicaid managed care organizations (MCOs) following North Carolina’s transition to managed care, implemented via a federal Section 1115 demonstration waiver.

Study Design: We conducted semistructured interviews with 41 individuals representing 26 provider organizations between March and July 2022 and with 47 individuals from 36 provider organizations between March and May 2023.

Methods: Our sample included health systems leaders, providers, and administrators from health system–affiliated practices, independent practices, federally qualified health centers, and local health departments. We coded and analyzed data using a thematic analysis approach.

Results: Of the 62 participating provider organizations, 34 considered staying with the same number of MCOs, 12 considered reducing the number of contracts, and 2 considered contracting with an additional MCO; others were undecided about their contracting decisions. Three primary themes emerged as drivers of provider exits from MCOs: (1) challenges in the contracting process, (2) increased administrative burden due to operational complexity, and (3) tension between sustaining access to care and maintaining organizational viability. Although many providers initially contracted with all MCOs, persistent operational inefficiencies led some to reduce or reconsider participation.

Conclusions: The complexity of managing multiple MCOs is a key factor in provider decisions to exit managed care networks. Policy reforms to standardize operational processes, improve transparency in contracting, and align administrative demands with reimbursement structures are critical to sustaining provider participation and ensuring patient access to care.

Am J Manag Care. 2026;32(9):501-507

doi:10.37765/ajmc.2026.90005

Takeaway Points

Although initial infrastructure helped independent practices transition to Medicaid managed care in North Carolina, escalating administrative demands and misaligned reimbursement threaten long-term network retention.

• Clinically integrated networks and other intermediaries were instrumental in helping independent practices manage contracting and operational complexities.
• Providers initially contracted with all managed care organizations (MCOs) to maintain patient access, but subsequent administrative and financial misalignment drove some network exits.
• Contracting challenges and reimbursement rate inequities were key drivers of provider decisions to exit certain MCOs.
• Administrative burden is a significant barrier to sustained participation. Navigating billing processes and prior authorization requirements increased workloads and costs without corresponding adjustments in reimbursement.

The transition of a Medicaid program from a fee-for-service model to managed care through multiple managed care organizations (MCOs) can significantly affect providers’ willingness to participate.¹ Limited participation or exit of provider organizations from managed care networks may exacerbate access issues for Medicaid enrollees, who already face significant health care barriers.² Studies have shown mixed results regarding access to health care services under Medicaid managed care. Some within-state comparisons, such as in Kentucky and Oregon, have demonstrated improvement in enrollees’ access to care.^3,4 However, other studies have shown reduced access to specialty care⁵ and no improvement in the quality of care^6,7 after transitioning to a Medicaid managed care program. Challenges in accessing primary care physicians may hinder Medicaid enrollees’ ability to receive preventive services, health screenings, and care for chronic conditions.^8,9

A recent study by Staiger et al evaluating the effect of a provider’s exit from a Medicaid managed care network on their patients’ utilization found a 5% decrease in the number of beneficiaries with primary care in the year following the exit.¹⁰ Disruptions in provider participation can lead to challenges in maintaining continuity of care for Medicaid enrollees, which is crucial for managing and coordinating care for those with chronic conditions.^7,10,11 Moreover, when provider organizations exit or choose not to participate in some managed care networks, Medicaid enrollees may have fewer choices when selecting health care providers.¹² This can reduce access to specialists, primary care, and other health care services.^10,13-16 Hence, understanding the reasons for providers leaving MCOs is critical to prevent the unintended negative consequences for Medicaid enrollees.

Provider participation in Medicaid managed care has varied because providers often voluntarily choose whether to contract with all MCOs, a subset of MCOs, or none at all.¹⁷ Studies have indicated that provider participation in Medicaid managed care is initially low and that some providers exit MCOs after their initial involvement.^5,11,18,19 For example, a recent study showed that 21% of participating providers exited at least 1 of Tennessee’s MCOs between 2010 and 2016.¹⁸ The reasons why providers choose not to join or decide to exit Medicaid MCOs are well-documented in some states. However, because each state is unique, expanding our understanding of these decisions is crucial.

In July 2021, the North Carolina Medicaid program transitioned to a managed care system run by 5 MCOs (4 statewide and 1 regional).²⁰ This transition was carried out under a federal Section 1115 demonstration waiver (ie, North Carolina Medicaid Reform Demonstration), which gives states the flexibility to test and develop innovative Medicaid delivery models.²⁰ The program planned to transition its enrollees with complex health care needs and intellectual disabilities to 4 regional MCOs in 2023, but this transition was later delayed to 2024.²⁰ Health care organizations could choose to contract with the MCOs to participate in the managed care model. Some documented challenges providers face when participating in Medicaid managed care include low reimbursement rates,^21-24 delayed reimbursement,²⁵ high claim denial rates,²⁶ and restrictive provider networks.^1,27 Although this evidence highlights the challenges that providers face when transitioning to Medicaid managed care, examining providers’ considerations for exiting MCOs in North Carolina would further strengthen and expand the existing evidence.

The consequences of providers not contracting initially or leaving MCOs after contracting can be multifaceted and particularly pronounced for Medicaid enrollees.^{7,10,11,13-16} This study examines the factors that influence provider organizations’ participation in or exit from MCOs under this waiver framework. It expands and strengthens the existing evidence, which can help develop Medicaid strategies that support providers and align with their needs and preferences. Ultimately, these insights can support the successful implementation of Medicaid managed care, benefiting the patients and communities served and improving health care access and quality.

METHODS

We employed a longitudinal, qualitative approach, interviewing a range of provider organizations at 2 points to understand the factors underlying their decisions to exit 1 or more MCOs. We identified potential interviewees from multiple sources, including data from the state’s Medicaid provider files and publicly available information (via web searches). We purposefully sampled provider organizations based on their proportion of Medicaid beneficiaries, specialty (family medicine, pediatrics, obstetrics-gynecology), ownership (independent medical groups and health systems), and geographic region.²⁸ We conducted outreach by phone and email. Between March and July 2022, we completed interviews with 41 representatives from 26 provider organizations. Between March and May 2023, we completed interviews with 47 representatives from 36 provider organizations. Interviewees included health system leaders (eg, chief financial officer), medical directors, clinicians, and practice managers (Table 1). Eighteen participants participated in both waves of data collection. Interviews were conducted via Zoom; each interview lasted 45 to 60 minutes and was recorded and transcribed. This study was approved by the Institutional Review Board at the University of North Carolina. Verbal consent was sought from participants at the beginning of interviews and deemed sufficient by the Institutional Review Board.

We used a thematic analysis approach to analyze data using Dedoose software (Socio-Cultural Research Consultants, LLC). We used a hybrid approach to coding our data: Three research team members (MA, CMS, PHS) developed a codebook deductively based on relevant literature and rapid analysis results and revised it inductively, drawing on themes that emerged in the data; 2 team members (MA, CMS) independently coded 5 interview transcripts to test the adequacy of the codebook, agreement on meanings, and application of codes. The agreement was 72% for the first 2 transcripts and 91% after coding 5 transcripts. Most disagreements concerned the clarity of code definitions. The 2 coders coded the remaining transcripts individually. The final codebook used in this analysis included 12 codes and subcodes, including initial contracting decisions, future contracting decisions, contract negotiations, and experience of working with MCOs.

RESULTS

In our total sample across both years, 40 of 62 participating organizations had contracted with all 5 MCOs, 12 with 4 MCOs, and 10 with 3 or fewer MCOs. The initial decision to contract with a limited number of MCOs was a strategic foresight by some provider organizations, given the complexity of working with 5 MCOs vs the previous state-administered, fee-for-service Medicaid system. Thirty-four participating organizations considered staying with the same number of MCOs, of which 30 had contracted through clinically integrated networks (CINs). Twelve provider organizations considered reducing the number of MCOs, 2 considered contracting with an additional MCO, and others were undecided. In our sample, 2 provider organizations reported exiting an MCO after contracting with it (Table 2).

We identified several factors that provider organizations considered when contracting with MCOs under North Carolina’s Medicaid managed care program. Given the longitudinal study design, we characterized factors influencing decisions to contract with MCOs at the launch of managed care and factors influencing decisions to exit contracts with 1 or more MCOs during contract renewal. Interviewees described several considerations related to the contracting process, increased administrative burden, and patient access to care.

MCO Contracting Process and Negotiation

Most provider organizations considered several factors important when contracting with Medicaid MCOs: the ease of contracting, availability of contracting support, negotiation of reimbursement rates, transparency and adequacy of reimbursement rates, and administrative issues during the contracting process.

Independent practices (32 of 34) in our sample relied heavily on CINs, accountable care organizations, or other intermediary contracting agencies to negotiate contracts with MCOs. This support facilitated contracting efforts and enabled independent practices to contract with all the MCOs. Health systems and larger independent physician practices negotiated with MCOs directly. For these participants, ease of contracting and negotiating reimbursement rates were often sticking points for contracting with MCOs. Interviewees shared that contracting was “easier with some MCOs than others” (leader, health system). For example, MCOs that had assigned representatives for provider organizations and readily answered questions regarding contracts were easier to work with. On the other hand, negotiating with each MCO was time intensive due to variations in contract terms and reimbursement rate discussions. A health system leader described their decision as follows: “We’ve talked about discontinuing or terminating some of the contracts, or one of them in particular. I’m not willing to budge on what I think it costs to do the work…and for several MCOs, we never got past that dollar amount. I’m not including administrative overhead costs for health finance to manage a network.”

Several other participants shared the same concern about the adequacy of reimbursement rates. They noted that although the state had set the floor rate for reimbursement, it was low to cover the cost of services. In addition, there was a perception that some health care organizations were negotiating higher per-member-per-month rates for care management services, raising concerns about transparency in negotiated rates. Participants suggested that contracting challenges and unsuccessful negotiations led to agreements with fewer MCOs. Consequently, 1 health system and 3 independent practices in our sample did not contract with at least 1 MCO. A senior leader at a health system–affiliated practice that contracted with 3 MCOs described the decision this way: “It’s an organizational-level [health system] decision.… What we hear from the conversations about why we haven’t contracted…is that there’s no transparency about the reimbursement and payment structure. And there’s no equity between the other systems in the area.”

Some participants also cited issues they encountered while administering the contracts as reasons for exiting an MCO. A practice manager from an independent family practice described the issues with the initial contracting process of an MCO they ultimately chose not to work with: “On the back end, the contract was never loaded, so the claims were denied, and [the MCO] never went back and paid the claims. I said, ‘But I have a completed contract. So you’re not even going to honor that?’ They said, ‘Well, it was never loaded.’ And I told the patients and my staff, ‘We will not take [this MCO].’”

Overall, most independent practices found contracting support from CINs beneficial, resulting in successful MCO contracts. However, some participants faced negotiation challenges during the transition to value-based payment models. This resulted in fewer contracts with MCOs and led some participants to consider exiting an MCO in the future. Moreover, provider organizations shared concerns about operational inefficiencies that put them at financial risk, which could be exacerbated under value-based payment models.

Increased Administrative Burden Due to Operational Challenges of Working With MCOs

The shift from state-administered Medicaid to 5 separate Medicaid MCO contracts increased administrative work for providers. Participants noted that several aspects of program management increased administrative costs and that the burden stemmed from operational challenges and inadequate responsiveness by MCOs to billing and prior authorization. Each MCO’s differing processes further exacerbated these issues.

The most common operational challenges described were attribution errors (incorrect list of enrollees on the provider panel) and higher rates of claim denials, which contributed to the decisions to exit 1 or more MCOs in the future. Participants described difficulty reconciling attribution errors because “some MCOs did not provide accurate attribution lists until October 2022, which is more than a year after the transition.” For example, participants from pediatric practices reported having adults assigned to their practices. Moreover, participants described that some MCOs “did not produce their lists in a way that could be reconciled with...electronic health records.” Participants shared that the unresolved attribution issues are detrimental to meeting
performance metrics.

Regarding denial of claims, a health system leader provided the following example: “What they’re asking us is to provide a notification of a sick baby, but it’s not like we have a coder right there, when we haven’t submitted this into our medical record or anything to that effect. All we know is that the doctor determined it was medically appropriate, given the circumstances, to elevate our care. And so it kind of sets us up for denials, and what happens next is that you involve physician advisers to overturn those denials. To do this, they need to review the medical record and explain what was occurring, which is a peer-to-peer process. That is too costly, and it’s untimely.”

Several other participants echoed this sentiment and attributed higher denial rates to unannounced changes to MCO adjudication systems. Reconciling patient lists and denials required significant time, with some lists lacking or requiring additional staff. These issues were further complicated when communication with MCOs did not result in resolution. One participant described navigating an MCO without an assigned representative as a “nightmare” for resolving issues and getting questions answered. Even when MCOs communicated, problems were often only temporarily addressed. Lack of MCO responsiveness and issue resolution significantly increased administrative burdens. Although some participants noted improvements over time, issues persisted with certain MCOs. Several organizations considered exiting MCO contracts because working through these “unresolved challenges was not worth it anymore.”

Participants described how MCOs’ differing procedures and processes, billing systems, and attribution methodologies exacerbate the administrative burden on provider organizations. A clinician at a small independent pediatric practice noted that each MCO “handles prior authorizations for the same treatments or services differently,” which was frustrating compared with the single process they were used to when Medicaid was administered by the state. A clinician-owner of a pediatric practice explained that “it has definitely created a lot more administrative burden. For example, prior authorizations have just been a nightmare. One of our good examples is the babies who need their RSV [respiratory syncytial virus] vaccine, their [palivizumab (Synagis)] vaccine. Each of the 4 [MCOs] had a completely different process for how that preapproval happened. For some of them, it was pretty straightforward and seamless; for others, it was a nightmare.”

Furthermore, there was no adjustment in reimbursement to accompany the increased administrative costs. Several participating provider organizations identified the misalignment between the increased administrative cost of operationalizing managed care contracts and the reimbursement rates as an initial contracting decision factor. A director of a local health department who decided not to contract with any MCO said, “The codes and amounts vary depending on the payer. So I was like, ‘One person can’t do this.’… So it came down to checks and balances. And knowing that we would be digging a monstrous hole to maintain that clinic…I was just like, ‘There’s just no way.’ So we started transitioning away.”

Interviews in 2023 showed that familiarity with operational processes helped provider organizations better manage complexity. However, the increased administrative burden and the challenges of obtaining accurate attribution lists without adequate reimbursement and incentives remained concerns among participating providers.

Patient Access to Care

Maintaining or improving patient access to care was cited as a primary motivating factor for contracting with all MCOs, both initially and in the future. This was particularly true for organizations that served a high share of Medicaid beneficiaries (ie, more than a quarter of their patients were on Medicaid), most of whom expressed concern about their patients’ ability to retain access to care. Participants perceived a lack of awareness among their Medicaid patients about the change to managed care. They said they believed offering all MCO plans was a strategy to ensure continued patient access.

A pediatric practice director described the decision this way: “We have a large population of [MCO] patients who would be harmed if we simply dropped them. So literally we have tried every other option to reach out, get better communication, get some assistance to work with [the MCO], but I don’t know how [to] get the message to the patients that ‘you have a choice, and just because they offered you a cell phone or they offered you a gym membership or they offered you a Visa gift card, it doesn’t necessarily mean you should have signed up with them.’ Nobody read the fine print. Nobody sort of understood that.”

This strategy was commonly cited by participants from local health departments, federally qualified health centers (FQHCs), and a few health systems as a part of the organizational mission, akin to “serving all patients regardless of their insurance status.” As one medical director suggested, “Not taking all MCOs…is creating a gap for patients” and “disrupting access to care.” Furthermore, participants perceived that exiting an MCO contract would “create an enormous burden of changing MCOs on patients.” Despite patient access being a common motivating factor for continuing to contract with up to 5 MCOs, several participants from independent practices said they would be willing to exit 1 or more MCOs in the future if the challenges of working with them persisted.

DISCUSSION

Our results highlight factors that influence provider organizations’ decisions to contract with or exit MCO networks in North Carolina. Motivating factors for initial participation or continued contracting included support from CINs and maintaining patient access. However, challenges during contracting, low reimbursement rates, and administrative burdens—such as high denials, attribution errors, and a lack of standardization among plans—were deterrents to continued participation.

CINs and other external agencies emerged as critical collaborators in helping small, independent primary care practices contract with MCOs and navigate the transition to managed care, underscoring their role and influence in negotiating contracts with MCOs. Additionally, studies have reported that CINs facilitate the establishment of data reporting, care management, and quality improvement infrastructure, which could serve as an additional motivating factor in maintaining MCO contracts.²⁹ In contrast, health systems and large independent practices reported that evolving value-based payment models, which require extensive contract negotiations, reporting, and more complex incentive structures, were major factors leading them to exit MCOs in the future. Lack of pricing transparency, including per-member-per-month payments for care management services, was identified as a deterrent during negotiations. Even though the CMS Transparency in Coverage final rule requires health plans and provider organizations to publicly disclose pricing and negotiated rates,³⁰ provider organizations may still benefit from real-time pricing tools and negotiated rates in standardized formats to compare rates during contract negotiations. Furthermore, MCOs need to continue sharing accurate, timely, and reliable attribution data to enable provider organizations to establish the reporting systems required to transition to more complex risk-based arrangements. Policy makers may promote transparency in how MCOs assign patients to providers and require regular updates to attribution lists in formats compatible with electronic health record systems.

The shift from a single payer to 5 MCOs with various processes, billing systems, and attribution methods has significantly increased the administrative burden on provider organizations. As the state adds more plans for children in foster care and individuals with special needs, providers may have to juggle 7 to 10 Medicaid MCOs, each with unique processes.^31-33 Consequently, some may stop accepting these complex patients to avoid further burdens. This increased workload adversely affects providers’ decisions to continue contracting with all MCOs, as studies indicate that primary care providers spend a quarter of their day on tasks such as prior authorization and electronic health record documentation.³⁴ Our study highlights the administrative burden on billing staff and the operational costs to manage various health plans while ensuring high-quality care. The state, MCOs, and providers should continue to work together to standardize processes such as claims payment, prior authorization, and attribution as the state moves to additional plans for individuals with severe intellectual and developmental disabilities and complex health care conditions,³² which could be another deterrent for contracting with new MCOs. Furthermore, policy makers should explore the feasibility of reducing the number of MCOs to streamline operations and reduce provider burden while maintaining enrollee choice and competition.

Patient access was a crucial consideration for provider organizations, particularly FQHCs, which primarily serve uninsured and Medicaid patients. These organizations are motivated to contract with MCOs to maintain access to their patient base and have a historical and operational commitment to Medicaid populations despite contracting challenges and administrative burdens.³⁵ Importantly, FQHCs have a different funding model with a mix of federal grants and cost-based reimbursement, which helps ensure their financial stability while maintaining access to low-income populations.³⁵

Limitations

This study is limited by its focus on 1 state. Medicaid programs vary by state, and factors influencing provider decisions may differ across regions, making it challenging to generalize these findings to other states or to the nation as a whole. Additionally, our study does not show how many providers left MCOs or exited managed care entirely, potentially because they served a higher proportion of Medicaid enrollees. However, a 2021 survey of North Carolina provider organizations found that nonparticipation in MCOs ranged from 5.8% to 36.6%.³⁶Future mixed-methods studies are needed to explore trends in provider participation in North Carolina over time. Lastly, the study did not include specialists or nonparticipating providers, who may have different considerations regarding participation in managed care that warrant exploration in future research.

CONCLUSIONS

This study identifies key factors influencing providers’ decisions to exit Medicaid MCOs, including contracting difficulties, administrative burdens, and reimbursement issues. Although patient access motivated initial participation, the complexity of managing multiple MCO contracts prompted many providers to reconsider their involvement. Support from CINs aided smaller practices, but continued provider engagement remains at risk without standardization and transparency in MCO processes. Addressing these operational inefficiencies and aligning reimbursement structures with administrative demands are essential to sustain access to care for Medicaid enrollees. n

Author Affiliations: Department of Population Health Management and Policy, John R. and Kathy R. Hairston College of Health and Human Sciences, North Carolina Agricultural and Technical (A&T) State University (MA), Greensboro, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill (MA, CMS, PHS), Chapel Hill, NC; Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina (CMS, VAL), Chapel Hill, NC; Division of Health Services Management and Policy, College of Public Health, The Ohio State University (PHS), Columbus, OH.

Source of Funding: North Carolina Department of Health and Human Services, Division of Health Benefits, supported this work through contract #30-2021-017-DHB.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MA, CMS, VAL, PHS); acquisition of data (MA, CMS, VAL, PHS); analysis and interpretation of data (MA, CMS, VAL, PHS); drafting of the manuscript (MA, CMS, VAL, PHS); and critical revision of the manuscript for important intellectual content (CMS).

Address Correspondence to: Monisa Aijaz, MD, PhD, North Carolina A&T State University, 1601 E. Market St, Greensboro, NC 27411. Email: maijaz@ncat.edu.

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