Physicians who have complained about late or denied payments from HMOs may feel heartened after hearing Florida has decided to fine HMOs for delaying or denying emergency room claims.
The Florida Agency for Health Care Administration fined five HMOs for such actions, one in July and four last month. The total amount of fines is $194,000, with more expected to be issued.
In March, the AHCA and the Florida Department of Insurance announced a joint audit of the state's 16 Medicaid and 35 commercial HMOs. Throughout the spring and early summer, AHCA teams conducted reviews of the HMOs' emergency claims processing practices and policies.
Investigators were trying to determine whether the HMOs are in compliance with a state statute that requires HMOs to pay for emergency professional and facility services, even when the treating physician determines that an emergency did not exist.
In other words, if a patient comes to an emergency room with abdominal pain, the treating physician may run a series of tests that show the patient has appendicitis, a true emergency. But if the tests show the patient simply has stomach flu, the plan must still pay for the professional and facility services because they were necessary to diagnose a possible emergency.
The auditors also looked at whether Medicaid HMOs were in compliance with the Medicaid Prepaid Health Plan contract, which requires plans to pay claims within 35 days and at the agreed-upon Medicaid fee-for-service rate.
In late July, Tampa-based Physicians Healthcare Plans became the first payer cited when it received notice from AHCA of a $26,500 fine: $4,000 for eight violations of the state statute requiring payment of emergency services, $13,500 for not paying claims within 35 days and $9,000 for not paying claims at the Medicaid fee-for-service rate.
The HMO was instructed that within 90 days of receiving the notice it must reprocess all denied or reduced emergency commercial HMO claims submitted from July 1, 1996, to the present and reprocess all denied or reduced Medicaid HMO claims from July 1, 1997, to the present. In addition, a corrective plan of action, including how such problems will be avoided in the future, must be submitted to the ACHA.
In August, Winter Haven-based Florida 1st Health Plans, Miramar-based Humana, Coral Gables-based Preferred Medical Plan and Tampa-based Well Care HMO suffered similar fates. The biggest loser was Well Care, which was fined $85,500: $5,500 for 11 violations of the state statute, $42,500 for not paying 85 claims within 35 days and $37,500 for not paying 75 claims at the Medicaid fee-for service rate.
Florida 1st was fined $21,500; Humana was fined $28,500; and Preferred Medical Plan was fined $32,000.
Well Care spokeswoman Nancy Gureau says the insurer plans to appeal the citation and is conducting its own review of the claims in question. About 10,000 physicians participate in Well Care HMOs.
Reviews of the state's other HMOs are ongoing, and more citations are expected, says AHCA spokesman Pat Glynn.
To date, one HMO has cleared the review process. Last month, Tampa-based HealthEase Health Plan was notified that it passed the review process and was found to be in compliance with both the Medicaid Prepaid Health Plan and state statutes.