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Agency for Health Care Administration

AHCA Solicits Nominations for Fraud Fighter Achievement Award

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The Agency for Health Care Administration (Agency) is now accepting nominations for the 2017 Fraud Fighter Achievement Award. This award recognizes an individual, team or entity whose efforts to reduce or deter fraud increased integrity in health care while supporting the Agency’s mission of providing better health care for all Floridians.
A nominee of this award may be a Medicaid recipient or provider, government official or entity, or a private citizen who demonstrates the Agency’s values of accountability, fairness, responsiveness, and teamwork in efforts that helped to detect, prosecute, or prevent fraudulent activity in health care.
Nominations will be accepted through November 3, 2017 and award winners will be recognized during Fraud Awareness Week (November 12-18, 2017). The nomination form and a list of past winners are available on the Agency’s website.
The Agency uses many techniques to deter fraud or abuse in the Medicaid program including, but not limited to:

  • Field initiatives that incorporate teams of investigators focusing on a single provider type making unannounced visits and specific checks regarding Medicaid billing, necessary medical services rendered, proper licenses, and certifications;
  • Third-party billing verification to ensure that Medicaid is the payer of last resort;
  • In-house data-mining and analytical efforts that allow the Agency to perform random audits of providers’ billing activities and run targeted audits of providers that bill outside the average for their provider type; and
  • Educational programs for providers to help them understand the Medicaid billing process, the laws, rules and regulations that apply to them as providers.

In addition, the Agency, in collaboration with the Office of the Attorney General, annually releases a comprehensive report highlighting efforts to reduce and deter fraud and abuse. Click here to view the 2015-16 Florida Medicaid Fraud and Abuse Annual Report.

Agency Statement on Deadline Extension for Florida’s CHIP Program

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The Agency for Health Care Administration today released the following statement regarding the deadline extension for the CHIP program in Florida.
“Ensuring that children have access to health care is one of our Agency’s top priorities, and the state will do everything in our power to help these families in the wake of Hurricane Irma.
“If a family contacts Florida KidCare and informs them that they do not have the means to pay the monthly premium, which usually ranges from $15 to $20 a month, Florida KidCare works with that family to determine if they are eligible for a lower-cost health insurance or Medicaid.
“We will do everything possible to ensure that families who are working with the CHIP system have coverage for their children. We have extended the deadline once already due to Irma, and we will look at further extending the deadline should the need arise. Before the deadline extension, Florida KidCare received timely payments for over 214,000 children. Since the announcement of the extension deadline, 490 children have been reenrolled in the CHIP program after making their premium payment.
“We will work with every family to ensure there is NO lapse in coverage due to Hurricane Irma. During the first week of October, KidCare began reaching out to families by telephone, text, email, and letter and it is possible that more families will take advantage of the deadline extension. KidCare will continue to communicate with families throughout the month.”
To qualify for CHIP, families can have incomes between 133 percent and 200 percent of the poverty level. This means the children in a family of four would qualify with an annual income between $33,000 and $49,000. If a payment is made at any time in October the coverage would be retroactive back to October 1, ensuring NO lapse in coverage. Our Agency has estimated that it would cost the state about $7.4 million dollars to waive premiums for one month, and the cost to the state would double to $14.8 million or more to waive premiums for enrollees for October and November in the CHIP program in the 48 disaster-declared counties.
Our Agency is encouraging families who may have been affected to call 1-888-540-5437 today and talk with a Florida KidCare representative about making a payment or to discuss other coverage options if their income and size of household has recently changed.

AHCA Announces Panel Members of Pediatric Cardiology Technical Advisory Panel

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Panel will establish standards for pediatric cardiac procedures

The Agency for Health Care Administration today announced the cardiology specialists and cardiac surgeons who will serve on the new Pediatric Cardiology Technical Advisory Panel (Panel). The Panel will fulfill the responsibilities outlined in Chapter 2017-151, Laws of Florida, signed by Governor Scott earlier this year. The Panel will develop procedures and standards for measuring the quality and outcomes of pediatric cardiac surgery programs in the state and make recommendations to the Agency on specific regulatory guidelines. Panel members include representatives from each of the state’s ten existing pediatric cardiology surgery programs, as nominated by the Chief Executive Officers of those hospitals, and three additional at-large members appointed by the Agency’s Secretary Justin Senior.
The Panel members are:
William Blanchard, MD – Retired. Formerly Sacred Heart and Nemours Children’s Clinic – Pensacola
Mark Bleiweis, MD – University of Florida Health Shands Hospital – Gainesville
Eric Ceithaml, MD – Wolfson Children’s Hospital – Jacksonville
Eric Eason, MD – Golisano Children’s Hospital SWFL – Fort Myers
Kristine Gulesreian, MD – Nicklaus Children’s Hospital – Miami
Jeffrey P. Jacobs, MD – Johns Hopkins All Children’s Hospital – St. Petersburg
Stephen Langley, MD – St. Joseph’s Children’s Hospital – Tampa
Jorge McCormack, MD MBA – Mednax Medical Group / Pediatric Cardiology Associates – St. Petersburg
David Nykanen, MD – Arnold Palmer Hospital for Children – Orlando
Frank Pigula, MD – Florida Hospital for Children – Orlando
Eliot Rosenkranz, MD – University of Miami Holtz Children’s Hospital – Miami
Frank Scholl, MD – Joe DiMaggio Children’s Hospital – Hollywood
Peter Wearden, MD – Nemours Children’s Hospital – Orlando
The Panel will convene in the fall and meet as needed to form their recommendations. The Agency has launched a dedicated webpage to make available information about the Panel’s work, member appointments, and meeting information. Under Florida’s Sunshine Laws, all Panel meetings will be open to the public. Members of the public may also send questions and information to the Panel through the website.
 

AHCA Takes Additional Action to Close Larkin-Owned ALF

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The Agency for Health Care Administration (AHCA) today has taken additional steps to remove Larkin-owned Floridian Gardens Assisted Living Facility from the Medicaid program. Floridian Gardens has a history of regulatory issues, and the Agency took action to deny their attempt to renew their license on December 22, 2016. The facility challenged AHCA’s action this January and this case remains pending. AHCA has now amended their denial to include information related to the tragedy at the Rehabilitation Center at Hollywood Hills, where 11 individuals tragically lost their lives due to the failure of Larkin management to timely call 911 or evacuate their patients. Floridian Gardens Assisted Living Facility and Rehabilitation Center at Hollywood Hills have common ownership.

Secretary Justin Senior said, “Our Agency will continue to hold health care facilities accountable, and we are fully committed to doing everything in our power to protect patients in Florida. The Floridians Gardens Assisted Living Facility and Rehabilitation Center at Hollywood Hills have demonstrated without a doubt that they do not deserve to be trusted with patient’s lives, especially those who are vulnerable and unable to care for themselves. That is why, in December, we took action to deny the Floridian Gardens Assisted Living Facility’s license renewal and why we are taking additional action today to remove this facility from the Medicaid program. Our Agency will work with our state partners at DCF and the Long-Term Care Ombudsman as well as our Medicaid program and Managed Care health plans to assist with resident notification of a closure, relocation options, and answering any questions that remain, to ensure a smooth transition for residents.”

Please see the timeline below of action AHCA has taken to hold Floridian Gardens Assisted Living Facility and Rehabilitation Center at Hollywood Hills accountable:

December 22, 2016
AHCA issues a Notice of Intent to Deny License Renewal Application to Floridian Gardens Assisted Living Facility in Miami. The facility challenged on January 17, 2017 and this case remains pending.

September 13, 2017
AHCA issues an Immediate Moratorium on Admissions, which stopped new patients from being admitted to the facility, for the Rehabilitation Center at Hollywood Hills.

September 14, 2017
AHCA issues an Immediate Suspension Final Order on participation in the Medicaid program to the Rehabilitation Center of Hollywood Hills.

September 20, 2017
AHCA issues a Suspension Order on the license to the Rehabilitation Center of Hollywood Hills, suspending their ability to operate a nursing home, and prohibiting the facility from admitting any patients.

September 22, 2017
AHCA files a motion seeking to issue an Amended Immediate Suspension Final Order on participation in the Medicaid program to the Rehabilitation Center of Hollywood Hills.

September 27, 2017
AHCA issues an Amended Notice of Intent to Deny License Renewal Application to Floridian Gardens Assisted Living Facility, and can be found HERE.

September 27, 2017
AHCA issues a notice to Floridian Gardens Assisted Living Facility outlining the intent to terminate them from the Medicaid program pending the effective date of the denied renewal of the license.  This notice is a Sanction Only Final Audit Report, and can be found HERE.

Assisted living facilities, nursing homes and hospitals are receiving frequent wellness checks

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Before, during and following Hurricane Irma, health care facilities throughout Florida have been implementing emergency plans to keep patients safe. The Florida Agency for Health Care Administration and the Florida Department of Health is conducting frequent and vigorous outreach to facilities every day, which includes daily calls with hospitals, nursing homes and assisted living facilities. In-person wellness checks are being conducted for facilities when contact cannot be made or any facility that reports distress. All facilities are being directed to contact 911 if patients are in jeopardy. AHCA is staffing the facility hotline 24 hours a day at 1-888-419-3456. Both AHCA and DOH are working around the clock to ensure all ALFs, nursing homes and hospitals have the resources they need.
Health care facilities have been provided with multiple pathways to communicate their needs with state officials and local emergency officials. This includes convening daily calls with facilities in advance of, during and after the storm. Reporting includes the online facility reporting database, FLHealthSTAT. These multiple mechanisms allow health care facilities to communicate needs to state emergency officials, including power outages, generator availability, fuel needs, spot coolers, ice and any other needs.
Hospitals, nursing homes, and assisted living facilities in Florida are required to have emergency operation plans. Requirements vary by facility type, but are all based in statute and rule. A complete list is available here. Hospitals, nursing homes and assisted living facilities are required to submit and receive approval for their plans from either the county emergency management or local county health department (this varies among counties and/or facility type).
Facilities that are not regulated by the state, such as retirement communities, are advised to call local emergency management or 911 if you are in need of support.
Power restoration remains a top priority for the state, particularly for facilities that serve vulnerable populations. As of this morning, more than 70% of power in the state has been restored.
STATUS AS OF 1 PM FRIDAY, SEPT. 15
Assisted Living Facilities:
193 are utilizing generators
1,978 have power
182 have reported as being closed
177 have reported post-storm evacuations
Nursing Homes:
34 are utilizing generators
669 have power
10 have reported being closed
40 have reported post-storm evacuations
Hospitals:
2 are utilizing generators
299 have power
8 have reported being closed
7 have reported post-storm evacuations

AHCA Announces Call for Nominations to Pediatric Cardiology Technical Advisory Panel

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The Agency for Health Care Administration (Agency) is issuing a call for nominations for cardiology specialists and cardiac surgeons to serve on a new Pediatric Cardiology Technical Advisory Panel (Panel). The Panel will fulfill the responsibilities outlined in a new law, Chapter 2017-151, Laws of Florida, signed by Governor Rick Scott earlier this year. The Panel is charged to develop procedures and standards for measuring the quality and outcomes of pediatric cardiac surgery programs in the state. The panel will make recommendations to the Agency on specific regulatory guidelines.
Panel members will include representatives from each of the state’s ten existing pediatric cardiology surgery programs, as nominated by the Chief Executive Officers of those hospitals and three additional at-large members to be appointed by the Agency’s Secretary Justin Senior. Additional eligibility information is outlined in the legislation. The Agency will accept nominations through the end of August and appointees will be announced in September.
The Panel will convene in the fall and meet as needed to form their recommendations. The Agency has launched a dedicated webpage at: www.AHCA.myflorida.com/PCTAP to make available information about the Panel’s work, member appointments, and meeting information. Under Florida’s Sunshine Laws, all Panel meetings will be open to the public. Members of the public may also send questions and information to the Panel through the website.

New Quality Scores Confirm Florida’s Medicaid Program is A National Leader

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The Agency for Health Care Administration (Agency) today announced that the Statewide Medicaid Managed Care (SMMC) quality scores for calendar year 2016 are the highest in the Florida Medicaid program’s history. This is the second full year of Healthcare Effectiveness Data and Information Set (HEDIS) quality scores for the SMMC program, and the results show an improvement in the overwhelming majority of these nationally recognized quality measures. Florida’s Medicaid program is one of the most efficient programs in the country, and our implementation to Managed Care stands as a national model. In calendar year 2016, Florida’s Medicaid health plans performed as well as or better than the national average on 59 percent of HEDIS measures.
Agency Secretary Justin Senior said, “What these scores really reflect is that managed care is working, and the program is providing even better quality care every year for the families we serve. In 2014 we transitioned the Florida Medicaid program to a Managed Care system, this roll out now stands as a national model for managed care and has made our program a more efficient Medicaid program. Our Agency’s goal is to provide better health care for all Floridians, and we are proud of how successful the program has been. We will continue to work with the health plans and providers to ensure that recipients are receiving the care that they need.”
The National Committee for Quality Assurance (NCQA) uses HEDIS to measure health plans on their levels of care and service. With Florida’s Medicaid health plans performing at or above the national average on 59 percent of HEDIS measures, Florida Medicaid has had an overall improvement of six percentage points over its 2015 scores and an 18 percentage point increase over plan ratings prior to the SMMC program.
31 reported measures showed improvement over last year’s scores, including:

  • Adult BMI Assessment
  • Adults’ Access to Preventive Care – 65+ years
  • Annual Dental Visit
  • Annual Monitoring for Patients on Persistent Medications – ACEs/ARBs
  • Annual Monitoring for Patients on Persistent Medications – Digoxin
  • Annual Monitoring for Patients on Persistent Medications – Diuretics
  • Annual Monitoring for Patients on Persistent Medications – Total
  • Call Answer Timeliness
  • Cervical Cancer Screening
  • Childhood Immunization Status – Combination 2
  • Childhood Immunization Status – Combination 3
  • Chlamydia Screening in Women – 16-20 years
  • Chlamydia Screening in Women – Total
  • Comprehensive Diabetes Care – Eye Exam
  • Comprehensive Diabetes Care – HbA1c Good Control
  • Comprehensive Diabetes Care – HbA1c Poor Control
  • Comprehensive Diabetes Care – HbA1c Testing
  • Controlling High Blood Pressure
  • Engagement of Alcohol and Other Drug Dependence Treatment – 13-17 years
  • Engagement of Alcohol and Other Drug Dependence Treatment – 18+ years
  • Engagement of Alcohol and Other Drug Dependence Treatment – Total
  • Follow-up After Hospitalization for Mental Illness – 30 Day
  • Follow-up After Hospitalization for Mental Illness – 7 Day
  • Follow-up Care for Children Prescribed ADHD Medication – Continuation and Maintenance
  • Immunizations for Adolescents – Combination 1
  • Initiation of Alcohol and Other Drug Dependence Treatment – 13-17 years
  • Lead Screening in Children
  • Postpartum Care
  • Prenatal Care
  • Well-Child Visits in the First 15 Months – 6+ visits
  • Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

For more information on the SMMC program, please visit our website.

AHCA Releases Invitation to Negotiate for SMMC Re-Procurement

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The Agency for Health Care Administration (Agency) released the Invitation to Negotiate (ITN) for the re-procurement of the Statewide Medicaid Managed Care (SMMC) program. The ITN can be accessed through the Florida Department of Management Services’ Vendor Bid System.
As stated in s.287.057(23), F.S., “Respondents to this solicitation or persons acting on their behalf may not contact, between the release of the solicitation and the end of the 72-hour period following the agency posting the notice of intended award, excluding Saturdays, Sundays, and state holidays, any employee or officer of the executive or legislative branch concerning any aspect of this solicitation, except in writing to the procurement officer or as provided in the solicitation documents. Violation of this provision may be grounds for rejecting a response.”
As a result, per s. 287.057(23) F.S., with the release of the ITN the Agency has entered into the statutory blackout period. The Agency will not have any discussions relating to the scope, evaluation or negotiation of those procurements.
To assist prospective plans in the development of their responses to the Statewide Medicaid Managed Care program Invitation to Negotiate (ITN), the Agency published a data book on March 30, 2017. The Agency held a public meeting on April 12, 2017 to present the data book and collect stakeholder questions. An updated data book and answers to questions received from stakeholders are included as exhibits to the ITN.
All health plans and potential bidders must direct their questions related to the SMMC procurement to the Agency’s Procurement Officer, Jennifer Barrett
Additional information about the SMMC re-procurement can be accessed here.

Prudential Productivity Awards Recognize Five Teams from AHCA

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The Agency for Health Care Administration (Agency) today announced that five teams of Agency staff members have been selected as winners in the annual Prudential Productivity Awards.
Agency Secretary Justin M. Senior, “I am honored to congratulate this year’s Prudential Productivity Award winners on their contributions to the Agency and the state. These employees found innovative solutions to complex issues in an effort to help Florida government operate more efficiently and reduce costs to taxpayers. Thank you for all that you continue to do for our state.”
Since the program’s inception in 1989, the Prudential Productivity Awards committee has received more than 16,000 nominations. The committee has given awards to state employees who have cumulatively saved or maximized more than $9.2 billion in taxpayer dollars.
The following Agency employees were selected as winners:
Business Analytics Team
Winners: Kimberly Noble, Emily Kinman, Bryan Cook, Barbara Fincher
The Agency saved thousands of dollars by organizing an Agency and Inter-Agency Tableau User Group. These groups train users on the fundamentals of Tableau, Tableau best practices, and serve as ongoing resources for help and trouble-shooting.
The Tableau User Groups fill the need of training new and experienced Tableau users. Training by Tableau is approximately $700/day per participant if the trainee travels to the training site (not including travel costs). Bringing a certified trainer to Tallahassee costs $1000/day per participant with a 12-15/person minimum.
Multiple agencies participate in the Tableau User Group and benefit from the cost savings. The Inter-agency group averages 25 attendees monthly (1.5 hours) from at least 10 different State agencies. The Agency group averages 15 attendees twice a month.
Estimated Yearly Savings: $101,250.00

Medicaid Provider Enrollment Streamlined Credentialing Team
Winners: Shawn McCauley, David Powers, Tamara Strayer, Nicholas Constantino, Ross Hart, Terry Schmidt, Pamela Hall
The team designed, developed, and implemented a streamlined Medicaid provider enrollment application, called Limited Enrollment, for providers seeking to participate in Medicaid health plan networks that eliminated an administrative burden on the plans, as well as providers who participate in multiple health plan networks.
The implementation of Statewide Medicaid Managed Care (SMMC) presented the Agency with two concerns raised by the health plans that this project addressed. Providers who did not want to fully enroll in Medicaid and were contracted with more than one health plan had to be fully credentialed individually by each health plan, providing the same documentation or variations for each. For providers who wished to fully enroll with the Medicaid program, the health plans had to wait until the enrollment process was completed before a Medicaid provider ID could be assigned.
The new process provides relief to the Medicaid health plans and providers from the administrative burden through a simplified process. The Limited Enrollment application serves as a single point of submission for provider data and eliminates duplicative submissions of data by providers to multiple sources.
Estimated Yearly Savings: $300,000.00

FLAIR Automation Team
Winners: Katrina Derico Harris, Sharon Dixon, Patricia Williams, Verionica Bishop, Cassandra Gainer
The automation of the Medicaid Accounts Receivables (MAR) to FLAIR upload has been implemented to eliminate the MAR revenue holding account and reduce the length of time to update the MAR and FLAIR accounts, to make recouped funds available sooner.
The automation eliminated the MAR holding account and reduced the time it takes to update the MAR revenue accounts in FLAIR. In the past, the money was deposited into the MAR holding account until it was determined where to allocate the funds.
The implementation of the automated process reduced the upload period from one week to a day, eliminated the manual process of preparing the spreadsheet, reduced the chance for manual entry errors, and made the fiscal year-end accounting process more efficient and accurate.
The implementation of the MAR FLAIR upload automation eliminated steps in the original process by eliminating the need for a revenue holding account. It also significantly improved year-end performance by allowing staff to work on other critical efforts related to closing out the Agency financials before June 30, 2017. This improvement has reduced processing time by 80% for all related transactions and reduce the amount of manual keystroke errors.
Estimated Yearly Savings: $7,341.55

Medicaid Exceptional Claims Processing Re-Design and Consolidation Team
Winners: Deborah Warfel, David Powers, Gayle Ninis, Catherine Eichenlaub, Catherine Nowotny, Don Fuller, Aaron Lounsberry, Sheila Gonzalez, Ondria Bacon, Teresita Fitzgerald 
The Medicaid Exception Claims Processing Re-Design Team developed and implemented a process that allows Medicaid providers to submit exceptional Medicaid claims directly to the Medicaid Fiscal Agent, bypassing the manual screening and tracking process previously performed by the Medicaid Field Offices, and allowing the Field Office staff to work the claims on-line.
An exceptional claim is a claim that would deny system edits of submitted directly to the Medicaid Fiscal Agent for processing, but the provider thinks that there should be an exception given due to special circumstances. In the past, providers submitted these claims in paper form, and each office scanned and entered them into the Claims Tracking System (CTS).
The original plan was for all field offices to work exceptional claims using the new process. The new system allowed the Agency to reorganize this process into a single Claims Hub office. Now all claims processors are working out of one centralized location, which has led to less quicker processing times.
Estimated Yearly Savings: $1.675 million

Florida Encounter Exchange and Expanded Benefits Project(s)
Winners: David Powers, Ross Hart, Michael Boston, Debbie Warfel, Teri Arnoldy, Mary McCullough, Erica Floyd-Thomas, Arlene Elliott, Kelly Rubin
To improve the Agency’s business need for receiving timely and accurate health plan encounter data that supports both capitation rate setting and monitoring of the health plan recipient services, the Encounter Exchange and Expanded Benefit Project Tteam developed and implemented new Florida Medicaid Management Information System (FLMMIS) encounter processing technical architecture.
The Agency needed a robust and informative encounter processing system to provide enhanced tracking and reporting of encounter receipts, processing, and operational functions, as a result of the implementation of the SMMC program and the new contractual health plan requirements. The encounter system redesign addressed the Agency’s business requirements to support the SMMC program, which serves over 3 million individuals enrolled in Medicaid at a cost of approximately $14 billion annually.
Estimated Yearly Savings: $0-24,999

AHCA releases statement on conclusion of Bayou Shores case

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The Agency for Health Care Administration (Agency) today announced that on June 5, 2017, the U.S. Supreme Court ended a Florida nursing facility’s three-year quest to avoid the jurisdiction of federal and state healthcare authorities. In 2014, Bayou Shores, a St. Petersburg nursing facility with a history of serious health and safety violations, attempted to avoid the termination of its Medicare and Medicaid provider agreements by seeking the protection of the bankruptcy court. The bankruptcy court obliged, forbidding the Agency and the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) from taking action against the Medicaid and Medicare payments. The Agency and CMS appealed the injunction, prevailing first in the U.S. District Court for the Middle District of Florida and again in the Eleventh Circuit Court of Appeals. The court of appeals issued an important page opinion last year supporting each of the Agency’s arguments regarding the federal government’s exclusive jurisdiction over this issue. The Supreme Court’s decision not to take up the case preserves this critical victory and ensures that the Agency and CMS can continue to cooperatively administer Medicaid and Medicare in Florida.
Agency Secretary Justin M. Senior said, “This is positive news for our Agency, and a vindication of all of the efforts our staff have invested to ensure that this facility was held responsible for the deplorable level of care provided. We have worked for over three years with our federal partners at CMS to defend this case. While bankruptcy courts tried to guarantee that this facility could continue receiving Medicaid payments, our Agency fought to have them removed from the Medicaid program, and all residents relocated because of the dire situation at the facility. Our Agency will continue to ensure that the facilities we regulate and participate in Medicaid are maintaining proper standards and providing the best care possible to patients.”
The Agency for Health Care Administration is committed to better health care for all Floridians. The Agency administers Florida’s Medicaid program, licenses and regulates more than 49,000 health care facilities and 43 health plans, and publishes health care data and statistics at www.FloridaHealthFinder.gov. Additional information about Agency initiatives is available via Facebook, Twitter and YouTube.