September 9, 2009
Senator Ronda Storms
313 E. Robertson Street
Brandon, FL 33511
Dear Senator Storms:
I am writing again on behalf of this agency and many others providing children’s
Medicaid mental health services in this state, to issues which continue to hamper our
delivery of appropriate services to the children and families who are in the most need of
this help. In the late nineties, a bold new effort was begun to redirect a portion of
Medicaid’s appropriations to provide mental health and hospitalization services to
Florida’s neediest children and their families. These entitlements took several forms with
names like SIPP (State Inpatient Psychiatric Program) and BHOS (Behavioral Health
Overlay Services) and focused on a system of care that provided bundled services at a
largely capitated rate. To enhance the delivery of services, documentation was
streamlined to afford clinicians more time with their clients than the ensuing paperwork
would require. These programs became popular and allowed organizations, such as ours,
to enhance their mental health services and work with a broader, more disturbed
population than was possible in the past. During its initial phase from 1999 through
2006, I felt that this system worked brilliantly despite the fact that the Agency for Health
Care Administration (AHCA) had no published manuals for a number of years (the
BHOS manual, for instance, was not published until October, 2003 and not distributed
broadly until January of 2004) and there was little to no training provided to early
implementers until the manuals were eventually produced. Still, as a tribute to those
providers, we were the ones that developed the procedures, designed the forms and
delivered the care that this new funding provided to us. At that time it felt as if the
floodgates for childrens’ mental health care had been turned wide open, and all for
$32.75 (the BHOS-CW rate) per child a day; less than the daily cost to board an animal at
the local vet.
Of course, that was then, this is now.
Today, while providers were able to avoid a 9% budget cut in these services during the
last legislative session, the daily reimbursement rates have not changed since their
inception back in the nineties. In a field where costs have risen by double digits each
year, this is unprecedented but is a testament to how well providers have been able to
persevere despite diminishing gains as a result of the increased complexity of delivering
childrens Medicaid mental health services. Today, providers are drowning under the
additional documentation, multiple audits and new requirements that become more
rigorous each year.
September 23, 2009
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Providers today are still using the same manuals that were produced in 2003 despite the fact that
the complexity of the documentation and delivery of service has risen well beyond the point of
absurdity. Clinicians across the board complain that the paperwork requirements have literally
exploded into highly detailed daily accounts which are in stark contrast to the weekly accounts
that were initially permissible and should still be so if one reviews the current rule manual. In
fact, in our agency, even the cottage parents are required to write detailed daily progress notes –
a requirement that was never asked of our cottage parents previously. Most cottage parents
employed in our agency complain that they are spending two to three hours nightly just writing
progress notes.
In 2006, AHCA contracted with First Heath, Inc. to perform statewide annual audits on Medicaid
providers. While Medicaid hailed this as a landmark in providing higher accountability, it has
instead produced a snarled tangle of audits and multiple repeat visits by auditors. The nature of
these audits has only lead to additional ill will, crushing paperwork and an opportunity for First
Health to reinterpret the Medicaid rule manual as they see fit. First Health’s influence has
become so predominate that AHCA has allowed First Health’s interpretations to supersede
AHCA’s own opinions. For the last several years since AHCA gave First Health the lead role in
managing the annual audits, inconsistencies in the way the rules have been interpreted have often
varied from reviewer to reviewer. A striking example is in the way a service known as
“Therapeutic Home Visitation” is viewed. In quoting the rules stated in Community Behavioral
Health Services Handbook (the Medicaid Manual), pg. 2-7-16):
“Therapeutic visits are visits the recipient spends with his or her biological, adoptive or
extended family or in a potential residential placement setting. Medicaid reimburses behavioral
health overlay services – child welfare when the recipient is absent up to 10 therapeutic visit
days per calendar quarter.”
Some First Health auditors have taken this to mean that youth should only be allowed to go
home at a slowly escalating variable (very limited home visits at the beginning of placement,
increasing as behavior improves while in care). Others have no issue with allowing up to 10
days provided that we adhere to the calendar quarter schedule. Depending on which auditor your
agency receives, your organization may be subject to a corrective action or it may not, it depends
on how the Medicaid manual’s rules are interpreted.
As it’s presently written, the current Medicaid Manual provides only an abbreviated overview of
BHOS and its documentation requirements. Until 2006, the AHCA staff that conducted the
onsite audits provided ample latitude to the programs over how to meet these documentation
requirements. The weekly summary written by the therapist was designed to be a composite of
the week’s events summarizing all the interventions that took place with each youth while he or
she was in program. Since First Health began auditing BHOS services, and at their insistence,
the weekly progress note has since evolved into a daily progress note format, thus eliminating the
paperwork efficiency that the original design sought to achieve. The escalating complexity of
daily notes has created a vastly burdensome documentation requirement. Across the state, most
BHOS providers have failed to meet the recent documentation requirements issued by First
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Health and AHCA. In 2008, only 5% of BHOS providers in the state were able to pass the First
Health annual audit.1
The process of addressing AHCA’s corrective actions (also known as Performance Improvement
Plans, or PIP) has never been fast, but at times has been excruciatingly slow. For example, in a
January 30, 2009 letter from an AHCA district representative sent to this agency, they
acknowledged receipt of a PIP that this agency had sent them on May 13, 2008 in response to
deficiencies noted in a site visit conducted on January 23, 2008. This PIP was approved on
August 21, 2008 and would be subject to a follow-up review slated for February 11, 2009; more
than one year after the original review. There is little explanation for these delays, but they are
known to be occurring for most BHOS providers throughout the state. The lack of timeliness
with this feedback system creates enormous re-certification problems and effectively prevents
programs from making needed changes, even if they are unrealistic.
There is also the issue of First Health’s position in the monitoring process. While it is no secret
that AHCA has voiced an interest in turning BHOS over to managed care for administration,
First Heath could not be in a better place to gain from its current position. Ethically, this
presents a significant conflict of interest which, so far, remains unacknowledged by AHCA.
Because First Health operates as a managed care entity they would be in an ideal position to steer
AHCA into a managed care agreement if AHCA ever decided to turn the administration of
BHOS over to a managed care corporation.
At the heart of this matter, has been AHCA’s own inability to demonstrate a leadership role in
this controversy. Over the previous year alone, representatives, of the Florida Sheriffs Youth
Ranches, First Health, the Florida Coalition for Children and other BHOS providers met with
executive leaders, including the Director of Medicaid, Dyke Snipes, on at least three occasions to
iron out differences, but with few results to show for the effort. AHCA managers themselves
have little experience with childrens residential agencies, and have expressed little desire to
understand their unique nature. As a consequence, the interpretation of Medicaid rules are more
in keeping with closed psychiatric facilities than the open community-based residential services
part of this funding was designed for. AHCA’s disinterest in this funding even extends to their
funding of staff charged with running it. Since 2006, there have been no fewer than four analysts
in charge of BHOS Medicaid. Since it is believed this position is merely a contracted position,
career AHCA employees are disinclined to apply. Hires tend to have a very limited
understanding of this entitlement funding with some being alarmingly unqualified. One analyst
hired several years ago was actually unaware of what the BHOS acronym meant. As of this
writing, it is not known if this position is occupied by anyone or not; the previous head
transferred to another position more than six months ago and there has been no word from
ACHA regarding any new replacement.
Lastly, there are the developing issues that are brewing within Medicaid’s fiscal agent, EDS. As
you might be aware, Medicaid changed fiscal agents last year on July 1st 2008 from ACS to
EDS. From the onset EDS had promised a more streamlined, Web-based billing system that
1
As stated by Paul Pearce, Florida Account Manager, First Health Inc., during the annual BHOS conference in
Tampa on10/09/08.
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would be more advanced and accurate, but simple to use. Unfortunately, these promises have
fallen well short of the actual practice. Though I can only speak from the perspective of one
Medicaid provider, it’s my belief that the issues surfacing at EDS are systemic and being
experienced by many more Medicaid providers in Florida, if not all.
Let me take the opportunity to list the issues we are currently dealing with:
For Behavioral Health Overlay Service (BHOS) providers, such as ourselves, all youth
who are enrolled in another HMO or Prepaid Mental Health Provider (PMHP) service
must be disenrolled from it prior to being certified to receive BHOS services. This is
essential because it keeps Medicaid from being charged twice for HMO/PMHP
enrollment fees and BHOS services for the same child. Unfortunately, EDS’ billing
system often fails to recognize this disenrollment even though Medicaid records verify
that the disenrollment did occur. As a consequence, when BHOS charges are applied in
this situation, EDS rejects them due to “lack of disenrollment.”
When electronic billing fails, such as in the example stated above, a HCFA 1500 paper
claim is filed as a way of recouping the rejected charges. In Medicaid terms this is
usually referred to as a “force pay.” Prior to EDS receiving these claims, they first have
to be approved by Medicaid at their local office. However, despite these preliminary
approvals, EDS will still frequently reject these “force pay” claims, usually providing the
same reasons for denial as before. As for other mental health charges not related to
BHOS, all “force pays” are summarily rejected by EDS due to “lack of disenrollment
from a previous HMO/PMHP” even though these are all legitimate claims and all have
been properly disenrolled.
EDS has ninety days to pay charges or provide an explanation for denial; a time factor
they always take advantage of and frequently go well beyond. If the denied charge is re-
filed this process begins all over again. Currently, 39% (63) of the 162 disputed claims
we currently have are aged over six months.
Because of various billing errors some claims have to be voided. This is a normal
practice with all providers. Unfortunately, the claim voiding option on EDS’ online
billing website does not work requiring providers to submit a paper claim to void a
charge.
In addition to managing the fiscal claims for Medicaid, EDS is also charged with
approving various provider certifications. For this agency, our clinical directors are
enrolled with Medicaid as “Type 7” providers which allow them to authorize BHOS
treatment services. Under normal circumstances this process can take several months,
but it is essential for efficient billing operations and this has to done for each new clinical
director we hire. During the last two clinical director hires, EDS lost the initial
applications from us. Each time an application is lost, the application process has to start
again from the beginning. There have also been circumstances where certain parts of the
application were apparently lost, but EDS would claim that these portions were simply
not submitted.
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Our frustration with EDS is compounded by the fact that there appears to be no avenue to resolve
these issues, or to even register complaints. It has now been a full year since EDS took over the
fiscal operations for Medicaid, but it would appear that problems with EDS have increased more
than they have improved. While not well known, EDS was said to have suffered a major system
failure on July 31st, which resulted in all Medicaid Recipients in the state being denied benefits.
In the meantime our disputed claims continue to accumulate each month.
These examples of poor execution, misguided oversight, and inability to marshal the type of
leadership necessary to properly guide and monitor this funding have lead providers of childrens
residential mental health in Florida to concede that we are at an impasse with AHCA. We are
requesting your assistance in the hope that your mediation will help break the stalemate and
address these escalating issues before they lead to an entitlement that entitles no one; where the
only group that this funding truly benefits will not be the children it was designed for, but the
corporations that simply monitor it and control its cash flow.
Senator, I represent a group of providers trying to make a difference in the lives of Florida’s
children. With your assistance you can help me further that cause.
Sincerely,
Bill Frye
Vice President, Programs
Florida Sheriffs Youth Ranches, Inc.
Board Chairman Elect
Florida Coalition for Children, Inc.
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