The Florida Medicaid Provider Agreement: What is it?
The Florida Medicaid Provider Agreement is a key component of the state’s healthcare landscape, governing the provision of medical care to low-income individuals and families. It is part of a broader social safety net, providing essential health coverage for those who meet certain eligibility criteria. This comprehensive guide will delve into the purpose and nature of this agreement, as well as the obligations and responsibilities it entails for participating healthcare providers.
At the core of the Florida Medicaid program is its ability to provide healthcare services to the poorest and most vulnerable residents of the state. The Florida Medicaid Provider Agreement serves as a mechanism through which healthcare providers, such as physicians, hospitals, and clinics, can participate in this public health insurance program. In essence, by signing the agreement, healthcare providers become "Medicaid providers", and are allowed to offer services and receive reimbursement for them from the program.
The Florida Medicaid program has an intricate structure, complete with multiple categories of services and provider types. The Florida Medicaid Provider Agreement categorizes providers according to their specialties and the type of services they render. For example, hospitals, nursing homes, home health agencies, and physicians are all types of Medicaid providers with specific agreements. It is worth noting that certain providers, such as emergency personnel, transportation providers , and laboratory service providers, may be granted direct access to the Medicaid program without a formal agreement.
The Florida Medicaid Provider Agreement is a comprehensive document that includes a wealth of information regarding administration, legal authority, and payment policies. Most importantly, it outlines the provider’s acknowledgment and acceptance of the rules, regulations, and requirements set forth by the federal and state governments. By signing the agreement, the provider agrees to comply with all applicable laws, and to provide the highest quality care as required by Medicaid standards. These obligations apply to all services rendered by the provider, whether or not the provider is obtaining payment through the Medicaid program. As such, providers should have a thorough understanding of the dozens of obligations that are outlined in the agreement, including the duty to provide reports, maintain records, allow for administrative review and audits, and safeguard sensitive patient information.
In conclusion, the Florida Medicaid Provider Agreement is an important part of Florida’s Medicaid program, defining the roles and responsibilities of participating healthcare providers. By joining the program, providers agree to comply with its requirements, and help ensure that low-income Floridians have access to essential medical services. An understanding of the agreement is critical for maintaining compliance, safeguarding patient rights, and ultimately delivering high quality care.
Florida Medicaid Provider Agreement Requirements
Healthcare providers that wish to enter into a Florida Medicaid Provider Agreement should be aware of the eligibility criteria that they will be required to meet for participation. Below is a list of the qualifications and certifications that are required:
Licensed hospitals and ambulatory surgical centers must be licensed by the Agency for Health Care Administration. If the services to be rendered require licensure or certification by the Florida Department of Health, the provider must have such licensure or certificate prior to executing a Medicaid provider agreement. A provider of hospital-based Medicare services (particularly services through a hospital outpatient department) should be currently enrolled in Medicare and comply with standard billing practices for Medicare reimbursement. Nursing homes must be licensed by the Florida Agency for Health Care Administration. Home healthcare agencies must be licensed by the Florida Agency for Health Care Administration. Home healthcare agencies must also be certified as a Medicare skilled home healthcare agency. Intermediate Care Facilities for the Developmental Disabled (ICF/DD) must be licensed by the Agency for Health Care Administration and certified by the Junior Medicaid Waiver Waiver program. Clinics must be licensed by the Florida Agency for Health Care Administration. A Federally Qualified Health Center must have a designation by the Secretary of the United States Health and Human Services under 42 U.S.C. § 1396b(a)(7). An entity providing medical transportation services must have a current permit (which is to be renewed annually) from the Florida Department of Highway Safety and Motor Vehicles. A provider’s license must not have been suspended or revoked. A provider must not have been excluded from participation in the Florida Medicaid program (or any other state Medicaid program) as a result of a fraud or abuse finding. The provider’s license must be current and in good standing. The provider must comply with the Secretary of Health and Human Services’ prepayment screening and other enrollment requirements. For certain types of providers, the provider must provide Medicare services to at least the level and scope provided under Medicare payment policies (and must participate in the Florida Medicaid program at that same level and scope).
Key Terms and Obligations
Under the Florida Medicaid program, the Agency has broad latitude to recover improper payments and discipline providers committing fraud or abuse. These providers are subject to the full panoply of enforcement actions under federal and state law. An often overlooked aspect of these enforcement actions, however, is the Medicaid Provider Agreement. As a condition of participation, a provider must execute a provider agreement with the Agency for Health Care Administration ("Agency"). This provider agreement may be used to establish violations of fraud and abuse laws and regulations, and is certainly fair game for a prosecutor investigating a Medicaid Fraud case. To what extent does the provider agreement set forth how a Medicaid provider will interact with the Agency and what obligations the provider has?
Provider Responsiblities Under the Florida Medicaid Provider Agreement These include an obligation to "fully comply with [state and federal] requirements," to "provide true, accurate, and complete information," to "screen its employees, agents, and contractors," to terminate employees and contractors convicted of certain crimes, not to discriminate on certain impermissible bases, and not to submit false claims. The provider agreement also requires the provider to "maintain written policies," as well as "effective controls against fraud, waste, and abuse."
Other Obligations Under the Florida Medicaid Provider Agreement There are other obligations under the provider agreement, but I hope this brief overview helps to highlight some key provisions in drafting an opinion letter, or conducting a Medicaid audits.
How to Enroll as a Medicaid Provider
The process for becoming a Florida Medicaid provider is as follows:
- Federal tax identification number. A health care provider must have a federal tax identification number prior to enrollment. Individual providers using their Social Security number in lieu of a federal tax identification number are subject to termination of enrollment in the Medicaid program if they obtain a federal tax identification number and fail to provide the Medicaid fiscal agent with that number within 30 calendar days of its issuance.
- Active licensure or certification. A health care provider must be licensed or certified in accordance with federally and state-mandated licensure or certification standards at the time of enrollment. (Physicians who practice under the supervision of a board-eligible supervisory physician are not required to have licensure at the time of enrollment, but they must have active licensure by the first day they perform or bill for Medicaid services.)
- Disclosure and information requirements. A health care provider must disclose certain information to the Agency. This includes, but is not limited to: photographs, names and addresses, medical staff certificates, FD&O certificates or Medicaid provider orientation certificate for each individual who has a 5 percent or more financial interest or ownership in the provider, social security number for each individual with a 5 percent or more financial interest or ownership in the provider, copy of any current legal business name registrations and documents, corporate charter, and copies of all disclosures previously filed set out in subsection 59G-4.010(2), F.A.C.
- Electronic funds transfer. Providers are required to request that payments be sent directly to their federally insured checking or savings account. Since all providers must electronically submit their claims, payment is made electronically pursuant to section 409.913(12), F.S. Electronic funds transfer is a condition of enrollment with the Medicaid fiscal agent. To enroll in the electronic funds transfer program, providers must complete a form provided by the fiscal agent.
- Fee. An application fee for newly enrolling providers is $500. As of July 1, 2013, the application fee is $500. Previously enrolled providers only need to resubmit the application fee if there has been a lapse in enrollment of 12 months or more.
Changes and Amendments to the Medicaid Regulations
The Florida Medicaid Provider Agreement has undergone significant changes to improve compliance and strengthen program integrity controls. Recent modifications to the Florida Medicaid Provider Agreement became effective on August 1, 2018 and reflected changes implemented with the passage of SB7026 in March 2016, also known as the Marjory Stoneman Douglas High School Public Safety Act. In keeping with that law, providers now attest to not including prohibited persons on employment rosters.
On May 1, 2018 the Florida Agency for Health Care Administration (AHCA) modified the Medicaid rules governing provider credentials and screening. Additionally, the Florida Medicaid "Provider Enrollment Web Portal" has been updated. These changes require all providers to login and visit the "My Profile" link and review their information to assure it properly reflects the changes that went into effect under the recently passed legislation.
Changes to the Provider Agreement formulary have also been implemented through the Portal. There are two new mandatory documents that need to be completed through the Provider Portal. The first is the Florida Medicaid Provider Agreement, and the second is the "Disclosure of Ownership and Controlling Interest" for individuals that will be furnishing services independently or in a group practice that is enrolled in Medicaid . These documents must be completed even if there is currently a Medicaid provider agreement for the provider, or the individual has previously completed the "Disclosure of Ownership and Controlling Interest" for a group practice.
Physicians and other non-physician practitioners who have both an active and a pending provider application will receive an automated message alerting them to; (1) complete the statewide Medicaid Agreement; (2) submit the Disclosure of Ownership and Control Form electronically; (3) review their data. Both now have a single signature line for the individual’s electronic signature. If the Provider Agreement is not updated, revisions will be required and will cause billing delays, denial of allowable claims and potential termination of your provider number.
Providers are required to comply with the Florida Medicaid Provider Agreement and any updates made to it. It is crucial, therefore, that providers understand the material changes and how the new provider Agreement, requirements, and changes, impact their practice. It is also important to emphasize that this article is not meant to serve as a general compliance guide. Rather, it is strictly a high-level summary of the most significant changes and updates to the Florida Medicaid Provider Agreement, and in no way addresses all changes. A review of both the old and new Provider Agreement is highly recommended prior to re-enrollment.
Frequent Issues and Resolutions
Practical Solutions to Common Challenges of the Florida Medicaid Provider Agreement
Disputes about appropriate billing and reimbursement
The primary billing and reimbursement in questions are generally stayed before the agency during the administrative appeals process—there are very few at the final agency order level. More frequently, challenges are first resolved in internal audits in the context of the agency’s quality assurance programs. In recent years, the agency has consolidated its fraud and abuse detection and investigation mechanisms under one roof, including the Office of Inspector General (OIG), which was originally separate from the agency. While the OIG set a directive in 2012 to reduce the number of administrative cases it pursues, the agency has continued with its investigative efforts. One way it does this is through the office of program integrity. The program integrity units of the agency investigate allegations that providers have violated requirements of the Medicaid program. Again, while many of the challenges are remedied by the provider during the audit process, some cases are devastating to the provider. For example, documenting an insufficient payment from a third party payer may be difficult, and if a provider has failed to do so at the time of the audit, it may in fact, be impossible—even if the provider was appropriately paid for the service. Other audits reveal long-standing problems unrelated to the underlying fraud and abuse issues. If the agency has not recently audited a Medicaid provider, it will often audit long-past periods, meaning that the provider may have difficultly remembering the procedural safeguards or retaining relevant business records from that time period. Exporting the Office of Inspector General investigative functions may not always be the best solution, as the agency maintains a vested interest in the payment and administration of the Medicaid program. While the existence of a public-private dispute may provide for increased checks and balances, other issues may arise. For example, as discussed above, a disputed audit previously considered administratively create a real possibility of inconsistent audit determinations—a competitive disadvantage to providers who are not selected for an audit, but who may respond differently to an audit in the event of a contested case. Not only does the office of program integrity issue exclusion recommendations, but the investigation panel reviews those recommendations and issues a notice of agency action to either exclude or not exclude the provider. A provider who is excluded can appeal the exclusion to an administrative law judge—however, practice varies across offices and districts, leading to different results within the state.
Lack of clarity in the law
One of the key issues providers face is the lack of clarity of the Florida law. There are numerous overlapping and intertwined federal and state statutes, rules, agency orders and policies that affect the legal landscape of the Medicaid provider agreement. From overall eligibility to billing requirements, provider agreements are affected by a myriad of laws. In addition to Florida law, providers are subjected to the broad parameters of the federal Medicaid/Medicare statutes and regulations. Federal law, including its broad language and enforcement policy, inform the agency’s interpretations of the provider agreement. The interaction of the various laws can create confusion about how to apply the law. Providers are often left to interpret ambiguous provisions or requirements without guidance from the government, creating a significant administrative burden. In the absence of clear guidance, providers should be prepared for the agency to rely on the agency’s own interpretation of the law.
The Importance of Compliance and Audit Readiness
For a provider, entering into the Florida Medicaid provider agreement is not the end of the relationship, but rather the beginning of an ongoing obligation to ensure that both the provider and its employees, agents, contractors, subcontracts, and other individuals or entities providing items and/or services under the provider agreement, remain in compliance with all applicable requirements.
Audits occur on a regular basis by various agencies and contractors of the Agency for Health Care Administration and the Department of Health. These audits are focused on the entire Medicaid program, areas of billing susceptibility, and high-risk providers and Medicaid contractor non-compliance. Program audits over the past decade have consistently resulted in findings and overpayment determinations related to noncompliance with the terms of the provider agreement. Some of the most critical areas for compliance measures include:
The above list is not all-inclusive and depends on the type of provider agreement and services offered. Each provider agreement has its own specific terms and conditions. Be sure to read the terms of the Medicaid provider agreement thoroughly before signing it.
A compliance and ethics program will help to identify and/or prevent activities that could lead to the above myriads of issues. The compliance program should also include a designated compliance officer whose job it is to monitor compliance. A compliance program must be communicated to all employees and periodically updated.
Provider Resources and Assistance
The Florida Medicaid program has a number of resources and support systems in place for providers. The Florida Agency for Health Care Administration supplies a host of online material for providers at its website. There they can find manuals, guides and materials for billing, participating in the disability and long term care waiver programs, Home and Community Based Services for Development Disabilities, Health Information Exchange, and patient monitoring. One such guide is the Florida Medicaid Provider Handbook: Provider Cost Sharing Handbook, February 2017, which sets forth all the information providers need to know in order to apply for enrollment into the Medicaid program, including the application process, review procedure, approval and enrollment status codes, and post eligibility requirements. The site also provides billing guides for individual provider groups such as physicians, physicians assistants, nurse practitioners, optometrists, pharmacists, psychologists, and others. These informational guides can be accessed online and in the form of downloadable booklets. The Agency also has a hospital outpatient enrollment form that can be downloaded from its web page , a Florida Medicaid program documentation standards information sheet, and information sheets detailing the necessary features of a Florida Medicaid payment plan (in digital and print formats). There is also a Florida Medicaid Provider Re-enrollment Guide prepared by the National Employer Services Company, Inc., and an enrollment form. The National Employer Services Company, Inc. also sponsors a Florida Medicaid Provider Enrollment page with additional downloadable information guide and data sources. The Florida Medicaid program also has an FAQ page for providers. Key professional groups for Medicaid providers include the Florida Academy of Audiology, the Florida Association of Rehabilitation Facilities, the Florida Association of Homes for the Aging, the Florida Association of Medical Equipment Suppliers, the Florida Association of Medicare Select Plans, the Florida Chiropractic Association, the Florida Health Care Association, the Florida Hospital Association, the Florida Medical Association, and the Florida Osteopathic Medical Association. Advisory services include the Florida Medicaid Services Integration Project.
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