Group of Florida doctors says leading Medicaid operator slow to pay

TALLAHASSEE, Florida — Hundreds of Florida’s most vulnerable children are stuck in the middle of a long-running financial dispute between doctors and the state’s largest Medicaid operator.

A group of physicians affiliated with Privia Medical Group, a Virginia-based network of health care providers that has a branch in Florida serving doctors' offices statewide, says it is owed $781,000 from Sunshine State Health Plan, a Medicaid managed care plan that oversees the most patients in the state.

Some of the bills date back two years, and the doctors claimed they were struggling to meet payroll and considering whether to stop accepting Medicaid patients in a state where nearly 50 percent of children rely on the insurance program for low-income residents.

“It's tough if you’re the only one in that area of the county that will take Medicaid,” Tara Forcier, a Brevard County-based pediatrician, said in a phone interview. “But what else can you do if you just can’t do it?”

A spokesperson for Sunshine denied that it is behind on the payment and said the company strives to quickly resolve billing disputes.

The group of pediatricians first brought the billing issues to Sunshine in June of 2022, and that was followed by a series of meetings where company officials were assured that the growing number of unpaid claims would be resolved, Forcier said. More doctors from outside of Privia’s network later joined the coalition. They told POLITICO that they had gotten nowhere with either Sunshine or the Florida Agency for Health Care Administration.

However, Sunshine began to pare down the $781,000 in unresolved claims after POLITICO began asking AHCA, the state agency, about them last month, Forcier said.

Forcier said that most of the unresolved cash had been paid by the middle of August but that there are some outstanding disputes over interest tied to the $781,000 in debt. She and the other doctors in the coalition who are part of the Privia network are from independently owned offices across Florida. Privia supports the doctors by providing services such as accounting and contract management. The network also created a fund from which doctors could draw loans to advance payments that had been delayed by Sunshine.

Sunshine Health spokesperson Lyndsey Brzozowski wrote in a statement that the state’s largest Medicaid operator manages more than 30 million claims each year, and each one is handled in a timely manner.

“When we learn of a claim or incentive payment issue, our team works to address and resolve them in a timely fashion,” Brzozowski said.

But Forcier and her colleagues are still frustrated with this experience. And Forcier said that while she feels compelled as a medical doctor to continue treating kids with Medicaid coverage, the billing delays are not sustainable.

“It never should have gotten to that point,” Forcier said. “The amount of time and effort that everybody has put into trying to resolve this issue, and the financial strain it's put on all of our practices — that part you just can't, you can't understate.”

AHCA disputes that the resolution between Forcier and the other pediatricians and Sunshine wasn’t timely. AHCA spokesperson Alecia Collins told POLITICO that Sunshine had already settled its debt by the time the complaint was received.

“The Medicaid staff sent the provider a resolution email, and to date, the provider has not contacted the Agency regarding any further issues,” Collins wrote in a statement. Collins also said the decision to dismiss the complaint was made after Sunshine Health told the agency that the $781,000 had been paid. AHCA for years has relied on self-reporting by Medicaid managed care operators to oversee health care for millions of recipients.

Forcier provided POLITICO with two years worth of emails, notes and letters. A review of emails provided by Forcier shows Sunshine either denying claims or promising to pay but not following through.

“Providers like myself across the state have been forced to put in more hours of unpaid work, staying up late to call, email and collect documentation to get Sunshine to follow through on their contractually obligated payments,” Forcier said. “It’s misleading to say we haven’t contacted the agency when we have evidence of those communications.”

Sunshine and other operators oversee HMO-style plans for the state for the 3 million Medicaid enrollees taking part in the state’s managed care program, which includes processing claims submitted by providers.

The Medicaid operator, which is owned by the St. Louis-based Centene Corp., has had run-ins with AHCA before. Sunshine Health has faced $28.6 million in fines levied by AHCA over the past five years — four times more than any other Medicaid operator that has been sanctioned by the state, according to a POLITICO review of a database of compliance violations maintained by the agency.

Much of that total came from more than $13 million in compliance violations found by AHCA during the last state fiscal year, which ended in June.

Two years ago, Sunshine was also hit with a $9.1 million fine after billing problems led some providers to stop treating disabled children and even close offices. The company partly blamed the problems on its merger with another Florida managed care operator, WellCare, which was announced in 2020. It is not just Sunshine that has been fined by the agency. AHCA launched a “desk review” of Medicaid insurance companies in the last fiscal year, which ended in June, which led to $28.3 million in fines for at least 14 managed care operators, including smaller companies that offer coverage for dental services and long-term care. Sunshine was hit with a $12.6 million fine from the review, which agency spokesperson Collins said was the result of the company failing to meet contractual performance requirements.

Brzozowski, the Sunshine spokesperson, stressed the size of the fine amounts issued by AHCA reflect the company’s 43 percent share of the state’s 3 million managed care recipients.

“Sunshine Health's $12.6 million in fines were part of nearly $22 million in fines issued to all Florida managed care organizations in FY 2023-2024, which is reflective of Sunshine Health’s market share,” Brzozowski wrote in an email.

The state has solidified its relationship with Sunshine. It is one of 15 insurance companies that are contracted to operate the state’s Medicaid Managed Care program, and it was one of the companies picked by AHCA in April to continue providing coverage for six more years in nine newly redrawn regions of the state. Collins, the AHCA spokesperson, said performance history was one of the factors her agency considered before it picked Sunshine among the 11 companies that expressed interest in the six contracts.

“All plans were selected through a competitive procurement process that evaluated vendors on multiple criteria, including past performance and compliance history,” Collins wrote, pointing to more information about the procurement process online .

Forcier said her Rockledge clinic, Pediatrics in Brevard, has also faced problems with other Florida managed care operators, but those issues were quickly resolved.

Given the likelihood of her patients having Sunshine coverage due to the company’s size, Forcier said the yearslong delays are crippling for business.

“It's definitely made my practice reflect on our payer mix and trying to determine whether or not we can afford to have such a high percentage of Medicaid patients,” Forcier said. “We take care of kids throughout the county, and having to shut down care for certain segments doesn't feel right.”