Medicaid Complaints From Health Providers Drop In FL

Dec 21, 2015

The number of health care providers complaining about the state’s Medicaid insurers is on the decline.

The report comes in response to complaints of providers who say they aren’t getting paid. First, a quick primer: Florida privatized its health care program for 3 million poor residents in 2014.

Now, the state pays private HMOs, who then pay the doctors. Midwives and other health care providers told WMFE they’re having major trouble getting paid, and some have stopped seeing Medicaid patients all together.

But the Florida Agency for Health Care Administration said complaints are down, and that overall, they represent a tiny fraction of the health care provider community.

To be exact, payment complaints come from three-tenths of one percent of Medicaid providers. 26 complaints came from midwives in the last eight months; of course, there are only 200 midwives in Florida.

Officials said the primary focus during the transition has been on patient issues, not provider problems. See below for the full statement:

During 2013 and 2014, we underwent the largest change in the Florida Medicaid program’s history. The shift to the Statewide Medicaid Managed Care program changed the delivery system for how our recipients received services and how our providers were paid. We expected a period of adjustment for both our recipient and provider population.

For this type of program implementation we expected that issues that arise immediately upon implementation would focus on recipients while they adjusted to the new program. Because of this, our primary focus during program implementation was preserving continuity of care, and to the greatest extent possible, ensuring recipients could keep primary care providers, as well as their prescriptions, and ongoing courses of treatment went uninterrupted. We also expected that there would be a period of adjustment for providers as with any new program. Therefore, another primary focus during implementation was ensuring that plans had the ability to pay providers fully and promptly to ensure no provider cash flow or payroll issues.

As you are aware, we created a centralized complaint process as a way to better track and respond to all complaints and issues received. We have encouraged that anyone encountering difficulties with health plans, such as delayed service authorization or payment, to inform us immediately so the issue can be handled as quickly as possible. We closely monitor all complaints from recipients, providers, and other stakeholders. This has allowed us to identify trends in issues and complaints and take action where there have been substantiated problems that needed to be addressed.

We expected that some providers would have difficulty adjusting to the new system, and have designated staff in a new unit who focuses on SMMC claims payment oversight.

SMMC contracts actually require that plans pay providers more quickly than ever before including:

• Health plans shall pay fifty percent (50%) of all clean claims submitted within seven (7) days.

• Health plans shall pay seventy percent (70%) of all clean claims submitted within ten (10) days.

• Health Plans shall pay ninety percent (90%) of all clean claims submitted within twenty (20) days.

The contracts we have with the SMMC health plans include the strongest contractual enforcement tools the Agency has ever had, including liquidated damages. When problems have been identified, we have used those contractual enforcement actions against health plans when determined to be out of compliance.

Overall the number of payment related complaints remain extremely low. We have validated the number of payment complaints in the graph included in the article, but the Agency recently completed the October and November monthly reports. The trend line for ‘Payment’ complaints appears to have declined, rather substantially, over the last two months. Please see the attached chart for reference. The article also references midwives and payment issues, however, the Agency pulled the number of complaints from a Medicaid Midwife provider, which involves payment for services rendered. Between April 2015 and November 2015, we have only received 26 payment related complaints relating to midwives. While this count is relatively low — the Agency has taken enforcement action, through liquidated damages, against a plan for incorrectly denying labor management services for licensed midwives.

It is also important to note that, although the article assumes that all ‘Payment’ complaints relate to provider billing, this is not accurate. ‘Payment’ reflects any complaint, from a recipient or a provider, which involves payment or billing. For recipients, this typically means they received a bill in the mail, that they feel should be covered by the Plan. For providers, the core complaint is typically that they haven’t been paid for services by a Plan. However, when working these complaints, we often find that the reason for nonpayment resulted, at least in part, from inaccuracies or inaction on the part of the provider. Examples of this include; a provider didn’t submit a “clean” claim to the Plan for payment (e.g. incorrect procedure code, wrong diagnosis, wrong NPI#, nonregistered rendering provider ID, etc.); provider didn’t complete the Credentialing process timely to become a network provider; provider didn’t obtain authorization to render service; provider didn’t check recipient eligibility and/or Plan enrollment, etc.

To put this in perspective, we have 112,368 providers who can participate in the program at any time. Seeing that only 349 providers submitted a complaint during the month of September 2015 (the month with the highest number of complaints in the time period reviewed) this still only represents about three tenths of one percent of providers submitting complaints. Also note, that even if a complaint is not substantiated, it is included in this count so it is likely than less than three tenths of one percent of providers presented a substantiated complaint during the month.

-- Reporter Abe Aboraya is part of WMFE in Orlando. Health News Florida receives support from the Corporation for Public Broadcasting.