Home-Care Firm Rules Medicaid Market

Sep 11, 2014

It’s much too soon to say whether this summer’s flood of Florida Medicaid patients into private managed-care plans will accomplish the state’s goals of improving access to care and saving money.

But one result is already clear: The overhaul is concentrating power in the hands of specialty companies over which the state has no direct control.  Some say one such company has essentially taken over home care services and equipment.

Univita Health, based in Miramar, has tied up so much of the market for Florida Medicaid health plans that many in the industry call it a monopoly. Managed care plans contract with Univita to manage their home-care business, even though the company itself is a provider of home-care and equipment to the same health plans.

In other words, Univita gets to decide whether a doctor’s referral for home care or equipment for a Medicaid patient should be awarded to Univita or some other company.

“If that’s not a conflict-of-interest, I don’t know what is,” said Fernando Gonzalez, a manager in his mother’s company, Health Medical Equipment in Miami.

Both the Florida Alliance of Home Care Services and the Florida Association of Medical Equipment Suppliers have complained to the state’s Agency for Health Care Administration, parent agency for Medicaid.

“AHCA says, ‘We can’t do anything. You have to work through Univita,’” said Ivonne Gonzalez, a board member of the equipment group.

Univita Health officials say they are complying with all regulations of the 2011 law that created Statewide Medicaid Managed Care. Florida Medicaid Director Justin Senior said that appears to be so; the law doesn’t specifically address this situation.

Senior said Medicaid officials can influence the behavior of managed-care organizations through contracts, but said they have no direct control over subcontractors like Univita. Senior said his staff told the plans they had better make sure Univita’s decisions are based on “arm’s-length transactions.”

“It puts a lot of pressure on us,” Senior said. “Somebody might not like (Univita’s dual role), but it appears to comport with the statute, and therefore we are not going to be taking any action.”

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Univita CEO Michael Muchnicki said his company is not a monopoly in Florida Medicaid, since it includes other home-care suppliers in each plan’s network. He said Univita decides which company will fill a particular need based on the type of service and how long it would take.

“My first goal is with the member and making sure they’re getting tended to in a timely manner,” he said.  “We’re doing this in the spirit of providing the most effective access to the member.”

Smaller competitors say that being listed on the network of an HMO doesn’t necessarily mean that Univita will send them business. The list is a “façade” created to make it appear that there are choices, said Fernando Gonzalez.

Officers of three home-care companies told Health News Florida they have had new physician referrals or even old patients snatched away from them by Univita. Since all information flows through Univita and only Univita can authorize a company to serve a Medicaid patient, they said, it would be easy for Univita to keep the more profitable cases while passing on the difficult, less profitable cases to other companies.

Medicaid’s Senior said he has received the message that providers don’t trust Univita “loud and clear.”

Not everyone agrees with Senior that state officials can do little to regulate sub-contractors. In a protest to AHCA in April, Florida Alliance of Home Care Services President Deanna Rollyson of Plant City wrote that Univita’s dual role appears to violate a portion of the state’s managed care law called “Any Willing Provider.” That provision says that any company willing to provide goods or services for the lowest price negotiated by the plan has a right to serve patients in that plan, assuming it meets standards for quality.

In other words, if a Medicaid HMO can rent a hospital bed for $200 a month from ABC Medical Supplies, the HMO must also allow XYZ Medical Supplies to be in its network if XYZ is willing to accept $200.  

“(W)e are certain the intention of the statute was to allow recipients and their physicians to choose the provider that best suits their medical needs and not to allow another party to make that decision for them,” Rollyson wrote.

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Some home care and equipment suppliers say they turned down contracts with Univita because they were offered only 50 percent as much as Medicaid has been paying them on what is called the “fee schedule,” its list of payments.

Donna Loggie, co-owner of Children First in Orlando, said she tried to negotiate with Univita on the grounds that her company cares for severely disabled children, including some on ventilators.

“Univita’s response was, ‘Well, that’s what we’re offering. You can take that or leave that. So we left that,’ ” Loggie said. “There isn’t a provider in the state of Florida that could sustain doing (this type of) business with 50 percent of the current Medicaid fee schedule.”

Univita’s Muchnicki wouldn’t discuss the company’s contracts, saying they are “proprietary” trade secrets. Similarly, Medicaid HMOs declined to discuss them.

On the company’s web site, Univita talks up the benefits of wearing many hats:  “integrating comprehensive home care services from a single source.” It adds: “By trading the traditional, fragmented home care system for our comprehensive, integrated model, we have reduced facility and readmission costs.”

The company says it accepts financial risk for the home care needs of patients in health plans, physician groups, and hospital systems, accepting a premium for each patient within which it must cover all home-care needs. Assuming it contracts that way with Florida Medicaid health plans, Univita would stand  to make money if it negotiates a 50-percent discount with other providers.

The health plans benefit because Univita assumes part of their financial risk and passes along savings at contract-negotiation time.

Florida taxpayers should also benefit if Univita drives down spending on home care, said Medicaid Director Senior. The state shifted to contracts and bids in part to get rid of inflation, fraud and abuse that afflicted the traditional fee-for-service Medicaid system, he said. 

Senior said the state has modeled its Medicaid makeover in some ways on the federal Medicare program’s gradual shift to competitive bidding for medical equipment and supplies.  Accountants reported the first round of bidding in 10 cities, including metro Miami-Fort Lauderdale and greater Orlando, saved $400 million for Medicare.  The program has been expanded to 99 cities, including 12 in Florida.

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One of the common complaints from home-care providers is that Univita Health makes it difficult to get an authorization to proceed with a service, and then makes it hard to get paid.  During the “transition period” after rollout of the Medicaid Managed Assistance program between May and August, the old providers were supposed to be able to submit bills for services and be paid within three weeks. The idea was to keep patients from falling through the cracks during the change in plans.

But that often didn’t happen, said Joan Cross, director of the equipment association. “They want to slow-pay. If they’re the only game in town, what are you going to do?” she asked.

The younger Gonzalez in Miami said in late August that his family’s company had more than 1,000 claims outstanding with Univita. “We’re not getting paid, period. We are now almost 7 ½ weeks into this program and we have yet to see a dime from Univita.”

And maddeningly, many say, they can’t get a response to their questions. For months, “I was on their back every day with e-mails and calls,” said Barbara DeFoe, general manager of One Source Medical in Clearwater. “I got some help the day I said my next call would be to the insurance commissioner.”

Univita CEO Muchnicki said providers’ complaints are probably driven by unhappiness with the reduction in payments driven by competitive bidding.

He said the company has no problem with payments, that it has a 97 percent on-time payment record as long as the claims are “clean,” meaning all the boxes on the form are filled in correctly, and the code numbers are right. He said that Univita has a new payment portal and it may take billers time to adjust.

Financed by private equity firm Genstar Capital LLC in San Francisco, Univita Health became a major player in Florida Medicaid rapidly by buying other companies, including:

·         Enurgi, a Web-based service for caregiver support based in West Palm Beach, in December 2009.

·         Atenda Healthcare Solutions, a Tampa-based home-health benefits manager, and its affiliates including Florida Home Medical Equipment, in January 2010. That provided 1.3 million patients in Florida and Georgia.

·         All-Med Services of Florida, which had spent 25 years building one of the largest integrated providers of home-based care, with more than 1 million customers. The March 2012 purchase boosted Univita’s patient base to 5 million.

On July 1, Univita Health moved its headquarters from a Minneapolis suburb to Broward County. Muchnicki,  formerly an executive with UnitedHealth and Cigna, was named CEO.

See related story: Will Low Bidder Care for Kids?

--Health News Florida is part of WUSF Public Media. Contact Editor Carol Gentry at cgentry@wusf.org. For more health news, visit HealthNewsFlorida.org.