Medicaid Provider Agreement Defined
A Medicaid provider agreement is a formal arrangement between the state of Florida and healthcare providers that allows those providers to receive payment from the federal government for services rendered to qualified Medicaid patients. Most people think about Medicaid in terms of payments for hospitalizations, doctor visits, and surgeries; however, Medicaid encompasses a number of different types of services, including long-term care services and providers.
In Florida, a Medicaid provider agreement is not something that only applies to hospitals. The Medicaid program is vast in the services it covers and the types of providers who can bill the program on behalf of the patients they serve. The following are some types of providers that currently hold Medicaid provider agreements and how their services are covered under the program: Over the past several years, the number of Medicaid provider applications we have filed has increased significantly . In the early years of our practice, we filed pretty much only physician and mental health provider applications. Today, we routinely file applications for providers such as skilled nursing facilities, assisted living facilities, durable medical equipment suppliers such as wheel chairs, ramps, and hospital beds, home health agencies, intermediate care facilities for the developmentally disabled, and private duty nurses. The list goes on and on.
The scope of medical service delivery through the Medicaid program continues to broaden as well. The issue is no longer just physician exams, MRI scans, and blood work. Operationally, Medicaid in Florida includes a long term care component, consisting of assisted living facilities (ALFs), nursing homes, home health agencies, and intermediate care facilities (ICF-DDs).
Requirements for Florida Medicaid Providers
Obtaining a Medicaid provider agreement is not as simple as joining the Medicaid managed care program. To be eligible for a Medicaid provider agreement, an entity must meet the following criteria:
a) Be a legal entity, such as a corporation, a limited liability corporation, or a partnership.
b) Be licensed and/or certified by the appropriate regulatory body in accordance with the rules set forth in the Florida Administrative Code and applicable federal regulations as a precondition to enrolling in the Florida Medicaid program.
c) Have an actual "presence" in Florida. A Medicaid provider applying as a hospital must have an inpatient facility or outpatient services in Florida; a provider applying as a nursing home must have a CMS-issued C.N.A. number; a provider applying as a broker must maintain a principal place of business in Florida; etc.
d) Except for Federally Qualified Health Centers (FQHC’s) and Rural Health Centers (RHC’s), be enrolled in at least one other commercial health insurance program prior to applying to enroll in the Florida Medicaid program. The insurer does not need to be a Medicaid managed care program.
e) Be enrolled and providing services in the Florida Medicaid program by the time the state completes its analysis and determines that the provider should be enrolled.
If the provider does not meet these eligibility criteria, it will not be able to obtain a Medicaid provider agreement.
Application for a Medicaid Provider Agreement
The Department of Financial Services administers the provider enrollment process for the Florida Agency for Healthcare Administration. The intermediary fiscal agent (IPA) acts as the point of entry for information to and from providers and the Florida Medicaid program. The IPA will notify providers when their application has been approved or denied. IPA contact information is found on the Provider Services Contact List. All required forms and instructions are accessible on the IPA’s website at www.mymedicaid-florida.com.
Providers must obtain a National Provider Identifier (NPI) number from the National Plan and Provider Enumeration System website. The Internal Revenue Service Tax Identification Number (TIN) must match the NPI. For the sole proprietor, the NPI number is identical to the TIN. For corporations, limited liabilities companies, or partnerships, the NPI number is the same as the Employer Identification Number (EIN). Providers and suppliers must enroll in and successfully complete the following:
- The online Enrollment Provider Update/Change System (E-PUPS) application
- Complete the Florida Business Entity Profile Form
- Complete the Florida Medicaid Provider Demographics Form
- Complete the Florida Medicaid Provider Administrative certificate of Insurance holder
- Pay all applicable enrollment fees. HMO plans, drop-in clinics, short term medical providers, and mobile surgical providers should not make a fee payment unless they utilize the Florida Medicaid Management Information System (FMMIS).
Florida Medicaid requires that all providers in the PAN-1 category, including those who render limited services, complete the Sunshine Health Florida Medicaid Provider Agreement. The only exception to this requirement is for providers who exclusively render immunizations or other vaccines. These providers must complete the Florida Medicaid Immunization Provider Agreement instead. After the IPA reviews the application and all of the supporting documentation for completeness and accuracy, the IPA will schedule an initial visit to verify the information in the application and to obtain additional information, if necessary. In addition to the required forms, the Application Request checklist provides a list of all other required documentation. If all documentation is present, the IPA will approve the application.
Medicaid Provider Agreements: Compliance and Regulatory Obligations
Section 7. Compliance and Regulatory Requirements
Upon acceptance of a Medicaid provider agreement, the provider and employees, and contractors, agents, and subcontractors of the provider that furnish medical assistance articles and services in Florida are required to comply with all state and federal laws and regulations applicable to the Medicaid program, as set forth in Rules 409.910, 59G-4.001, and 59G-4.200, F.A.C. Florida Medicaid providers must comply with many requirements as a condition of participation, including but not limited to: The foregoing list is not exhaustive, though it does highlight the main compliance obligations. A full list of requirements is set forth in Rule 59G-4.200, please see Rule: 59G-4.200.
Advantages to Becoming a Medicaid Provider
In Florida, one of the most common types of Medicaid provider agreements is in the scope of billable medical services. This may include some type of ambulatory (outpatient) service not requiring a general hospital’s acute care services. Examples of distinct and autonomous billable services would be these:
This is a partial list of billable medical services that may be provided in exchange for reimbursement from Florida Medicaid. Two popular types of providers will be discussed in upcoming articles, as many of you have questions surrounding their operation: home health agencies and assisted living facilities.
With so many providers in Florida who accept and bill for services to Florida Medicaid, it comes as no surprise that there are many advantages to becoming a Medicaid provider. These include, but are not limited to , the following:
The financial incentives of being a Medicaid provider in Florida are boosted when a provider participates in managed care programs. An example is the Statewide Medicaid Managed Care (SMMC) program. Under this program, Medicaid beneficiaries receive coverage from managed care plans through one of three ways: Managed Medical Care (MMA), Long-Term Care (LTC), or Specialty Long-Term Care (SMTC).
Enrollment in a managed care plan may bring more patient access to a provider than under traditional fee for service. Managed care plans, such as those created under SMMC, have obligations to their members to provide services and pay out fees. Providers who participate in managed care plans are guaranteed – through the provider agreement – to be paid for the services they provide to members under the plans.
Challenges and Common Mistakes
- Complex Terms of Art. Medicaid regulations are not just administrative guidelines, they are complex requirements that implicate many different sections of the Code of Federal Regulations (CFR). Different states use different regulations, and the Florida Agency for Health Care Administration and the Agency for Persons with Disabilities vary in their implementation of these regulations. For example, the 50-page Florida Medicaid provider enrollment application has 21 pages of instruction on how to complete the application and dozens of cross-references to specific provision of the Social Security Act and the Code of Federal Regulations. While providers should carefully read the entire Medicaid provider agreement between themselves and the state, cross reference to the Code of Federal Regulations is required to completely understand the agreement. Providers should not rely on their success of completing other government forms to conclude that Florida Medicaid entity agreements are simple or straightforward.
- Inconsistency with Other Statements. Oftentimes, the terms in a Medicaid provider agreement cross reference federal law or state rules, and may appear to conflict with the Medicaid provider agreement itself. Providers should not try to reconcile these inconsistencies on their own. Consulting with an experienced health care lawyer can save providers headaches and thousands of dollars later if an agreement is not properly completed.
- Scope of Services Affect Provider Type. Medicaid provider agreements often include many different types of Medicaid covered services, and many different Medicaid provider types. For example, a provider agreement may include billing terms for home health and adult day care services, and discharge planning, respiratory, and personal care services. The different Medicaid provider types often require different provider numbers to be able to bill for each service. For example, a hospital cannot bill for air carrier services with it’s hospital NPI number.
- Florida Medicaid Volumes. The Florida Medicaid program is one of the largest in the United States – larger than California. The size of the program means that Florida has thorough and complex rules governing its administration. A minor error on a Florida Medicaid enrollment form can result in months of delays, and numerous follow up phone calls and letters. It is often more efficient for large organizations to hire a health care lawyer experienced in dealing with Medicaid administrative appeals than it is to try to navigate the process on their own.
Recent Developments
The recent passage of HB 385 called the Managed Medical Assistance (MMA) change bill sets forth an alternative payment model to encourage primary care providers to establish care management teams. While the Department of Children and Families and Agency for Persons with Disabilities have their own specialized services, the Department of Health’s new primary care medical model focuses on providing preventative and behavioral health care and are designated to "promote more coordinated, cost-effective and efficient care."
The proposal to create a medical home model for managed medical assistance recipients allows providers to be reimbursed for professional visits that are not face-to-face and for services that are not related to a specific illness, injury, or diagnosis. There are concerns that the Department of Health may not be in full compliance with AHCA and the Agency for Health Care Administration is requesting that AHCA be authorized to develop spot audits of these agreements.
In addition , recent changes to the Florida Medicaid Electronic Health Records (EHR) Incentive Program include extending eligibility for the program through December 31, 2021, in accordance with the final rule on "Stage 3" of the Medicaid EHR incentive program, which was published in the Federal Register August 3, 2015. In addition, those determined ineligible due to "unforeseen barriers" faced due to the transition from ICD-9 to ICD-10 code sets are eligible for the incentive program.
On November 6, 2015, the Centers for Medicare & Medicaid Services approved a new 1915(b)(c) managed care waiver. The state’s 1915(b) Managed Medical Assistance waiver includes Florida’s program to manage long-term care, obstacle removal services, transportation and managed medical care for recipients under the federal Supplemental Security Income (SSI) program; the long-term care portion of the 1915(b) waiver will be implemented July 1, 2016.