Diagnosis for 3.28.22: Checking the pulse of Florida health care news and policy

Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.

Sunshine Health, the state’s largest managed care vendor operating in its Medicaid program, has remained relatively quiet since it was revealed last week that the Agency for Health Care Administration (AHCA) had levied more than $9 million in fines and sanctions on the company.

Sunshine has not said whether it plans to contest the fine. The fine would be a record since Florida shifted the operation of the mammoth health care safety net over from a fee-for-service model to one that relies on private managed-care companies to coordinate care for the majority of more than 5 million people enrolled in Medicaid.

But it may be worth looking at how Sunshine has fared in other disputes of late.

A recently released report shows that a statewide claims dispute panel reviewed six cases against Sunshine Health in 2021 and found in favor of the provider in five of the disputes. Ultimately, the company was ordered to pay Jackson Memorial an aggregate of more than $380,000 for the five disputed claims. The sixth claim was withdrawn.

The same panel reviewed four cases involving disputed claims against WellCare. Two of the claims, one filed by Jackson Memorial Hospital and the other by Cauffield and Associates, ultimately were withdrawn. The panel ordered the health plan to pay the full disputed amounts in the remaining two cases, totaling $122,705.15.

The panel was initially created 20 years ago to consider reimbursement claim disputes between health care providers and managed care plans. Over the years, the program has been broadened. And in 2018, the state required Medicaid managed care organizations to use the arbitration process for disputed claims.

AHCA administers the program, but Maximus Inc. is the company the state contracts with to mediate the billing disputes. Users bear the program costs, with the losing party picking up both its costs of the claim review and the prevailing party’s costs. In instances where Maximus favors both parties, the review costs are shared.

In all, the panel agreed to review 73 of the 111 claims filed with it for review.

The largest Medicaid dispute the panel heard in 2021 involved Molina Healthcare of Florida and Children’s National Medical Center. The provider’s case alleged $2.3 million in underpayments. Maximus agreed, according to the report.

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— PARTING GIFT —

State workers, legislators, and other top state officials got a little going away present, courtesy of the Florida Legislature.

Earlier this Session, Diagnosis flagged proposed changes to the state’s group health insurance program. Many changes wound up passing in the waning days of the 2022 Session with scant questioning or debate.

One notable change approved allows state employees with group health insurance who step down from their job on or after July 1 of this year to be eligible for enrollment in the state group health insurance plan for another two years following their departure. There is a caveat: only state employees who have been cumulatively employed for six years could take advantage of the health insurance option.

But this also means that someone who has been in and out of state government — but worked at least six years in a state government job — would get a chance to do this. Initially, the House wanted to have a limited two-month special open enrollment period where this option would be available for former employees. But the final bill (HB 5009) that passed unanimously allows former employees to join the state group health insurance plan for up to two years following their departure.

The premiums, however, would not be at the active employee rate. Instead, the bill clarifies that these departing state employees would pay the same rate as early retirees, which currently is $813.46 a month for individual coverage through a standard PPO/HMO and $1,831.08 for family coverage.

— BUT WAIT, THERE’S MORE —

As they have done for many years now, lawmakers kept the health insurance premium rates for state workers (and themselves) unchanged. But the same bill that opened coverage options for departing state workers did two other things of note.

The measure finally repealed the tiered-coverage system, pushed through by House Republicans in 2017, that kept getting delayed.

That law directed the Department of Management Services (DMS) to offer state employees access to one of four health insurance plans — named after metals with different actuarial values, like Obamacare’s bronze, silver, gold and platinum plans. Employees who chose less expensive plans than what the state paid toward the premium could be used to increase their salary. An actuarial analysis showed that the law, if implemented, would have increased costs by $525 million annually.

The bill that will be sent to Gov. Ron DeSantis, however, would create for the first time a dedicated “anti-fraud” unit inside DMS where workers would investigate claims as well as any fraudulent actions by vendors that work with the state group health insurance program. The newly approved budget sets aside money for three positions in the new unit.

In other moves involving state workers, legislators ordered DMS to hire an outside company to create a “wellness program to treat, reduce and prevent obesity and obesity-related conditions.” Lawmakers say that those employees who enroll in the program would gain access to U.S. Food and Drug Administration-approved medications to treat chronic weight management problems. But the language, which was tucked in the back of the budget bill, says this treatment would not become available until 2024.

DMS has until March 2023 to produce a draft contract and provide costs on how much the wellness program would cost.

Legislators also have OK’d spending more than $2 million for a “new case management and analytics solution for health care fraud,” as well as $600,000 to hire an outside independent benefits consultant to do a “comprehensive cost containment analysis of state employee and retiree health benefits.” By mid-January, DMS must submit a report with recommendations needed to implement any cost containment measures.

These moves came nearly two months after economists revised the fiscal outlook for the state employee health insurance program, which is projected to spend $3.1 billion in the next fiscal year. But the fund, a combination of employees’ monthly premiums and state tax dollars, is projected to have a $61.8 million deficit in the Fiscal Year 2023-24. The deficit is due to a decline in health plan enrollment in the Fiscal Year 2021-22 and higher than anticipated expenses for those covered. Data show 3,312 fewer state employees in the health plan in the current fiscal year than projected.

— WHY IT ALL MATTERS —

This year, more than 171,000 people are covered by the state group health insurance program.

About 88% of active full-time staff, or 129,098 employees, enrolled in the state group health insurance program for 2022 coverage. Of those, about 40% of employees enrolled in an individual health insurance plan. Another 55% of state employees enrolled in a family plan and about 4% enrolled in a spouse plan.

Another 6,842 part-time employees also enrolled in the health insurance program in 2022. About 69% of those employees chose an individual health insurance plan compared. Thirty percent chose family coverage, and less than 1% chose spouse coverage.

— TIME TO STUDY —

Every year, state legislators call for an extensive line of reports and studies to be done in the coming year — and there were plenty they tucked inside the budget that will be sent to Gov. DeSantis in the near future, including a couple in the health care arena.

For example, lawmakers provided $100,000 for the Department of Health to study the long-term health impacts of exposure to blue-green algae and red tide toxins to both residents and visitors — both of which are environmental hazards that could prove deleterious to the state’s vital tourism industry.

The state has been providing funding for several years on studies designed to look at the effects of harmful algal blooms to understand their health effects better. Both Florida Atlantic University and Florida Gulf Coast University have been evaluating the long-term and short-term health effects of exposure to toxins.

Last November, FAU researchers announced they were following 102 applicants and were trying to recruit 50 more for this year. As part of its research, the university announced that it would “explore if there is a relationship between a history” of getting infected by COVID-19 and “susceptibility to the effects of harmful algal blooms exposure.”

— ROSTER —

— Edward Jiminez, Chief Executive Officer of University of Florida Health, is one of four candidates the South Broward Hospital District Board of Commissioners will interview for president and CEO. Aurelio M. Fernandez III will retire April 30. Other candidates who will be interviewed are Jonathan W. Curtright, Chief Executive Officer, University of Missouri Health Care; William Jackson, Jr., M.D., president, Chief Executive Officer, Erlanger Health System in Tennessee; and Scott Wester, president, Chief Executive Officer, Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana.

— Delray Medical Center Chief Operating Officer Maria Morales Menendez was included in Modern Healthcare’s 2022 class of Top 25 Emerging Leaders. Delray Medical Center, part of the Palm Beach Health Network, is a 536-bed acute care hospital that has served the communities of South Palm Beach County.

— ICYMI —

In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.

Largest plan, largest fine — Florida’s largest Medicaid managed care vendor, which came under scrutiny for failing to pay claims for sick children over several months, is being fined a record $9 million by AHCA. State regulators are also placing sanctions on Sunshine State Health Plan and requiring the managed care plan to take “corrective” actions before members can be auto-assigned to the plan.

New hire — Brock Juarez, formerly the Director of Corporate and Strategic Initiatives at Florida Healthy Kids Corporation, is the new Communications Director at AHCA. The top communications post was vacant for three months before Juarez was hired.

Good idea — The Army has scrapped its move to have a physical fitness test that is gender- and age-neutral and will now allow women and older soldiers to pass while meeting some reduced standards. The decision comes after a study by the RAND research organization confirmed that men were passing the new six-event fitness test at a much higher rate than women and that older soldiers were also struggling with their scores in the expanded, more difficult test developed in 2019.

Why all the secrecy? — Florida’s top Medicaid official met Tuesday morning with the state’s 15-member advisory committee, but there was no talk about how the state plans to determine Medicaid eligibility for 5.1 million people once the nation’s public health emergency expires.

Birth and death — Florida deaths outnumbered births during the height of the 2020-21 COVID-19 pandemic by more than 45,000 people, slowing the Sunshine State’s otherwise impressive population growth, according to new estimates released Thursday by the U.S. Census Bureau. Overall, from July 1, 2020, to July 1, 2021 — the snapshot period used for the Census Bureau’s new estimates released Thursday — Florida’s population grew by 211,196 people. That’s an increase of just under 1% over those 12 months.

— FOR YOUR RADAR —

Aside from coverage by Florida Politics, these stories are worthy of your time.

“One of Brevard’s only mental health crisis units about to close amid care shortage” via Eric Rogers of Florida Today — Rockledge Regional Medical Center will close its dedicated, 24-bed behavioral health inpatient unit and no longer accept Baker Act patients after April 20, hospital spokeswoman Cathy Pague told FLORIDA TODAY in an email. Pague said the hospital has partnered with Circles of Care and Palm Point Behavioral Health, which run the county’s only other two mental health crisis units, to “transition care of current patients and to ensure the Brevard community has access to the vital care it needs.”

“Nurse convicted of neglect and negligent homicide for fatal drug error” via Brett Kelman of Kaiser Health News — RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide Friday after a three-day trial that gripped nurses across the country. According to the Nashville district attorney’s office, Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions.

“Concerns rise as a U.S. reimbursement fund for testing and treating the uninsured for the virus stops taking claims” via Ellen Barry of The New York Times — As the White House pleads with Republicans in Congress for emergency aid to fight the coronavirus, the federal government said that a fund established to reimburse doctors for care for uninsured COVID-19 patients was no longer accepting claims for testing and treatment “due to lack of sufficient funds.” Some U.S. health care providers are informing uninsured people they can no longer be tested for the virus free of charge and will have to pay for the service.

“U.S. Supreme Court says Navy can limit deployment for unvaccinated” by Greg Stohr via Bloomberg — A divided U.S. Supreme Court said the Navy can limit deployment and training for 35 Seals and other special operations forces who are refusing on religious grounds to get vaccinated against COVID-19. Granting a Joe Biden administration request over three dissents, the justices partly blocked a federal judge’s order that required the Navy to assign and deploy the sailors without regard to their unvaccinated status. The order will apply while litigation over the Navy’s vaccine mandate goes forward.

“Physician sentenced to prison for health care fraud scheme” via the Department of Justice — A Florida physician was sentenced today in the Southern District of Florida to two years in prison for a health care and wire fraud scheme involving the submission of false and fraudulent claims to both Medicare and a financial services company that offered consumer loans to patients for out-of-pocket medical expenses. According to court filings and evidence presented during court proceedings, Mark Alan Zager, 72, of Miami, conspired with Dennis Nobbe, a now-deceased chiropractor and owner of Dynamic Medical Services, located in Hialeah, Florida, to defraud Medicare, individual patients, and a financial services company. Zager opened a merchant account in his own name and allowed Nobbe to use the account in exchange for paying kickbacks and bribes to Zager. Through the account, Nobbe routinely applied for loans on patients’ behalf, purportedly for services that would be rendered months in the future but were not provided.

— PENCIL IT IN —

Wednesday

Noon. The Alzheimer’s Foundation of America will hold an online event titled “Latino Healthy Brain Summit: Una Mejor Calidad de Vida,” for Miami-area residents. Register here.

12:30 p.m. The Florida Boards of Medicine, Osteopathic Medicine and Pharmacy, Joint Rules Committee meets. Call (888) 585-9008; participant code: 599196982.

Thursday

Rep. Dana Trabulsy‘s birthday.

10 a.m. The Florida Board of Medicine — Finance & Process Accountability Committee meets. Meeting link here.

11 a.m. AHCA holds a meeting on Rule 59G-4.085 regarding early Intervention Services. Place: Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee. Or register for the hearing here.

11 a.m. The Florida Board of Medicine Council on Physician Assistants meets. Meeting link here.

Saturday

10 a.m. Rep. Daisy Morales, an Orlando Democrat, and Orlando City Commissioner Tony Ortiz will hold an autism awareness event. Englewood Neighborhood Center, 6123 La Costa Drive, Orlando.