HMOs fined $4M for denial of services

Two health plans in Florida have been fined a total of nearly $4 million after a long-running dispute about whether they improperly denied or reduced speech-therapy services for children in the state's Medicaid program.

Florida's Agency for Health Care Administration (AHCA) imposed a $2.7 million fine on Amerigroup Community Care and a $1.3 million fine on UnitedHealthcare of Florida. The agency determined that Amerigroup inappropriately denied or reduced services to 531 children; it targeted 522 violations by United, according to the Miami Herald.

United issued a statement saying it will appeal the fine. "UnitedHealthcare believes that it has acted appropriately in connection with managing the speech-therapy services on behalf of the state and its Medicaid members. Based on a preliminary analysis, UnitedHealthcare has concluded that the vast majority of these members were approved to receive speech-therapy services," Health News Florida reports.

In a letter to Amerigroup, AHCA alleged that the company and a subcontractor sometimes determined therapy needs were educational, rather than medical. In doing so, Amerigroup would deny or reduce services and refer children to services provided by schools. AHCA added that it has no evidence Amerigroup notified recipients of their appeal rights when services were bridged or reduced while transitioning to the school system.

Michael Garner, president of the Florida Association of Health Plans, said the dispute boils down to different interpretations of requirements and a lack of clarity in contracts between HMOs and the state. He told Health News Florida that health plans have tried to act in good faith. "The solution to all of this is just contract clarity. It's as simple as that--making sure the contracts are clear," Garner said.

To learn more:
- read the Miami Herald article
- see the Health News Florida story

Related Articles:
Amerigroup's $225M fine may not benefit providers
 
Insurers with high profits asked to decrease premiums
 
Increases in healthcare premiums may be here to stay

Suggested Articles

In a letter, 111 physician organizations weighed in on surprise billing, urging Congress not to turn more power over to health insurers.

Even when taking into account increased resources, general and vascular procedures performed in teaching hospitals are better for high-risk patients.

As members of Congress wrangle over the best way to stop surprise medical bills, one senator predicts Washington will pass a new law soon.