Episode 45 - Florida Medicaid 80% Contracts: The Fight for Fair Reimbursement and Access to Care

Aaron Marshall (00:23)
Hey everyone, welcome to the Spot Growth Podcast. This is your host, Aaron Marshall with Extra Mile Billing. And today I've got a couple of guests who have been working on a problem that I think Florida therapists know well and good. We've had a bit of an issue over the past few years, especially since the new ACA contract was issued where

therapy practices are being offered 80 % of the Medicaid rate reimbursement. And this has been a little shocking for folks. It's not a new practice, but it's been happening more and more. So it's something that your friends and your fellow clinic owners and your state organizations have taken on as something that they want to really help practice owners with and really out of the

out of the guidance of their hearts. mean, they're doing this. So I wanted to introduce two guests that I have today, Tara Hawkins and John Eddenfield. Welcome you guys.

Tara Hawkins (01:32)
Hello.

Jon Edenfield (01:33)
Good to be here. Thank you.

Aaron Marshall (01:34)
Yeah. So, Tara is a current practice owner and also a huge advocate at the state level and has helped us with so many things to include getting your Medicaid rate increase. And John is a former practice owner, but also helps manage a segment for a much larger statewide practice in their mergers and acquisitions segment, which I think we'll probably have to do a different episode on that at some point in the future,

Jon Edenfield (02:03)
Sounds good. Yeah.

Aaron Marshall (02:05)
All right, guys. Well, ⁓ I guess, Tara, if you could just share a quick overview of this issue that you've been working on and what's been happening at the legislature level and really what the issue is in general.

Tara Hawkins (02:17)
Yes. So back in 2023, there was a Medicaid rate hike committee that we all worked together to work on getting that Medicaid rate increased. So myself, another clinic owner, Amy Brurick, we went around to legislatures, spoke to them about an increase and provided a bunch of data as to why we were in desperate need of this increase. Then in

2024 came around, we had the Live Healthy initiative that was passed. Yay, therapy providers, we got the increase. So excited. We win.

Aaron Marshall (02:57)
Huge victory,

Jon Edenfield (02:57)
Yeah.

Aaron Marshall (02:58)
huge victory across the state. 13.5

% increase. mean, that's a great, amazing outcome.

Tara Hawkins (03:01)
Yeah.

Yes, so we went from one of the lowest Medicaid reimbursement rates to like the eighth lowest. So we're moving up in the country. We're going in the right direction. ⁓ But then unfortunately, in January, February of this year, we started finding out that these new providers who are trying to provide services to ⁓ kids are now only being offered 80 % contracts, meaning that

Jon Edenfield (03:14)
In the country. Yeah. Yeah.

Aaron Marshall (03:15)
Right direction.

Tara Hawkins (03:35)
their contracts they're stating that they're only going to get reimbursed 80 percent of that Medicaid rate. So it was very hard to hear ⁓ as we worked so hard for the increase for everyone. Not just ourselves, we wanted it for everyone and then now we're speaking with legislators and ACA to be able to resolve the issue. ⁓

Aaron Marshall (03:41)
Hmm.

Yeah.

Okay, so for some of our owners, like some people are saying like 80%, what does that mean? What's actually happening there? Could you just kind of clarify and just give us a picture of like, why is that so important to clinic owners to only get 80 % versus 100 % of the Medicaid rate?

Tara Hawkins (04:14)
Yes, so when we say that MMAs are only offering 80 % contracts, it means that these insurance companies are only paying therapy providers 80 % of the state's Medicaid rate, and that you can look up online and see their fee schedules. So if you have 100 % contract right now, you're getting $81.32 per hour. Great.

So, but if you have an 80 % contract, you are only getting $65 and like six cents per hour.

Aaron Marshall (04:46)
Hmm.

Jon Edenfield (04:47)
Which Aaron

is actually a decrease from our previous fee schedule rates, right? And if I could just jump in for a second to support what Tara's saying is it's really a supply and demand. And we're probably preaching to the choir here if practice owners are listening, but our margins in the pediatric therapy business are razor thin. So every penny counts and it comes down to supply and demand. If we have a lower rate, which is why

Aaron Marshall (04:54)
Right.

Jon Edenfield (05:16)
We went to the legislators to tell them, you you ultimately have an access to care problem here, okay? If we can't attract quality therapists to our businesses, then we can't, we don't have the providers to help these children who are in need of services. And so that's why we went and just to, you know, add historically, we've only had two rate raises.

in over 30 years in this industry. One was at about 5 % around eight to 10 years ago. And then rapidly after that, managed care came into play and did not, wasn't required to pass that along. And then the other one was the most recent one, which was you talked about as the 10 to 13 % rate raise. And I, you know, we believe that those providers really need that extra 10%.

Aaron Marshall (06:00)
Mm-hmm.

Jon Edenfield (06:14)
to attract therapists into the field of pediatrics rather than going to a higher reimbursement like Medicare or something like that.

Tara Hawkins (06:23)
Yep. the problem is that, yes, they can state 80%, but you have room to state, no, I want 100%. The issue is that they're coming back stating that you can't negotiate those rates basically, because when they try, the plans tell them that they have met network adequacy, meaning that the MMA is claiming that they have enough providers in the area. They don't need to offer you a better rate.

Aaron Marshall (06:24)
Absolutely. Well, sorry, go ahead, Tara.

Tara Hawkins (06:51)
But the issue is they are most likely counting therapists who aren't treating, who aren't adding new clients. So on paper it looks like the access is fine and that there are enough therapists. But in reality, there's not enough therapists and there really isn't network adequately.

Aaron Marshall (07:08)
So that's a big issue here, and that's an issue that I've heard pop up time and time again, is this word or this phrase called network adequacy. And I think it's been an easy thing for plans to hide behind, that term network adequacy. So could you just define a little bit what that network adequacy means and ⁓ what you're doing to kind of combat that claim of network adequacy?

Tara Hawkins (07:36)
Yes, so network adequacy, is a federal and state requirement that MMA care plans. They have to have enough providers in network to give patients reasonable access to care, meaning families should not have to drive too far for care or they should not have to wait too long for services. And the issue right now is just how it's measured. So the plans, they self report their network adequacy to OCA.

⁓ And those reports usually count every licensed therapist, but the reports tend to be inaccurate because many times providers are on there who have maybe moved away or retired, they haven't come off the list yet, so it's not truly accurate. I do feel like, John, that they mentioned the separation between adults and pediatrics now, Aka.

Aaron Marshall (08:24)
Hmm.

Jon Edenfield (08:30)
Yeah,

that was one of the things in our Alliance Conference where we were able to talk directly with both Sunshine, one of the larger health plans, and ⁓ folks straight from OCA. And we're able to question them about that. And both of them listened to us. understand that they differentiated between network adequacy and access to care. So.

Just to try to make a quick point, network adequacy may mean, hey, I have 100 providers on my list. But really, access to care is when a parent calls, starts to call down that list, hey, we've got a waiting list. We can't get you in. You might try these down the street. they keep going down. And as we all know, those parents keep going and going. We hope they don't give up. But they're having a really hard time finding a provider. On top of that,

Aaron Marshall (09:18)
Yeah.

Got it.

Jon Edenfield (09:28)
You have incidents of certain conditions like autism is, you know, is increasing. mean, some say as much as one in 12 at this point. So the demand is increasing and the supply is decreasing. And that's why it's so important for us to go and educate these legislators, you know, like Tara's doing going around with the Alliance and, and educating them on the fact that these children are not able to get in.

And that's why we need the increase to be able to support that.

Aaron Marshall (10:01)
So I understand ⁓ what you're saying is there is data that the providers have access to that really could help build this case. And I think that's something that I've seen that you guys are working on. Tara, could you just tell us a little bit about how you're trying to gather data to be able to support this case that there is not real network adequacy?

Tara Hawkins (10:25)
Yes, so, and this is what we did back in 2023 with the Medicaid rate increase. Really what those legislators look at is that data to prove it. We can't just go in there saying we need the increase just because. We have to have the data for it. So now after speaking with some legislators, they wanted more data, so we made a survey.

And that's a huge part of the effort. So we're collecting statewide data from all pediatric therapy clinics to show what's really happening on the ground that on paper everything may look good, but on the ground it doesn't. So we're asking questions like how many kids are on wait list? Or if you don't take a wait list, how many kids are you sending off to other clinics each week?

Aaron Marshall (11:13)
Yeah.

Tara Hawkins (11:15)
to show we really need to prove that access to care issue. That data is really critical because right now ACA is saying that they don't see an access to care issue. So they aren't aware of it. But every clinic owner you talk to, I mean, has huge wait list. So there's where the issue is. So we really need that data to help prove our point.

Aaron Marshall (11:39)
So how many responses do you currently have? And I guess what would be your goal to make this data really meaningful for the legislators?

Tara Hawkins (11:47)
Currently, I think last time I checked it was around 75ish responses. I'm looking for 100 and above, which I don't think is a hard ask because last time when we collected data for the rate increase, it was around 250 responses. Yes. Yep.

Aaron Marshall (11:52)
Yeah

Mmm, yeah, yeah.

Jon Edenfield (12:04)
And look, it worked, right?

Aaron Marshall (12:07)
It did.

Jon Edenfield (12:07)
They listened, they saw the data and they implemented the change that we asked for.

Tara Hawkins (12:13)
Yes, the data is gold.

Aaron Marshall (12:15)
Wow,

no, that's huge. And how long does it take to fill out the survey? I mean, it's got to be like a five minute survey, right? I mean.

Jon Edenfield (12:21)
Probably

less than that, right? It's like it's not nine questions. I think Tara and you know, we've had we've had some really ⁓ some great responses. I'm sitting here looking at the graph. I don't know if you can see this. So the green the green is the amount of providers who are reporting that they have 10 or more. Children on their wait list, right? Less it's 99 % of current respondents have indicated.

Tara Hawkins (12:23)
Yes, very.

Aaron Marshall (12:35)
of

Wow. Wow.

Jon Edenfield (12:49)
that they have 10 or more children on their wait list with only less than 1 % reporting that they don't have a wait list. So like Tara said, there's a differentiation between what ACA is seeing and what we as providers are seeing in the real world.

Aaron Marshall (12:52)
Wow.

I'm telling you that there's no reason why we shouldn't be able to get 250 to 300 of these surveys back. mean, you know, there's enough, you know, clinic owners out there. Where have you put access to the survey right now? Like if somebody wanted to go fill this survey out, where would they go to?

Tara Hawkins (13:27)
Currently it is on the Facebook group page. The Florida private practice OTPT speech that one it's on there and the most recent survey that I've posted would be on there and Jennifer volts also reposted it as well. It's called the OCA Let me look OCA Medicaid waitlist is the name survey. We can also email it to people

Aaron Marshall (13:34)
Yeah. Right.

Got it. Yep.

Tara Hawkins (13:57)
And we also ask that if you have it maybe on Facebook and you know other clinic owners aren't on Facebook, please email it out to them so they can fill it out as well.

Aaron Marshall (14:04)
Yeah.

And we're going to post it on our SpotGrowth ⁓ Facebook website as well, because we've got about 450 folks in there ⁓ and growing. So that'll be another place you can access it. Is it anywhere accessible on maybe like the Alliance for Pediatric Therapies site as well?

Jon Edenfield (14:26)
Absolutely. So we've got it on the it's www.allianceforpediatrictherapies.com and we would like to ask people to join. We restructured recently. It's a $200 membership for a full year. You get a free access to our annual conference that we just had. Virtual happy hours with other providers for networking. And look, it's just important for us all to work on this together, right? We've all we're all in this together. Like I said, these

Margins in our business are razor thin and you know, we need we need to fight for the increase. So we ask anybody who wants go to www.allianceforpediatrictherapies.com and join us.

Aaron Marshall (15:02)
Absolutely.

You guys are doing the hard work. So I'm just asking the listeners, do the easy thing, fill out the survey. I'm going to put a link to that survey in the description of the podcast. So if you're listening to this podcast, just do me a favor, go click that link, submit that two minute survey. Let's just blow this up. Let's blow them up with data so they can go back to those legislators and really build the case.

Jon Edenfield (15:15)
Yeah.

Tara Hawkins (15:16)
Yes.

Aaron Marshall (15:37)
and get these 80 % contracts to stop. mean, at the end of the day, this impacts you. These are the people on the ground doing the hard work. So please just jump in there, help them out, submit these surveys, join the Alliance, and let's just keep these advocacy efforts going because this is so critically important. And this is the start. mean, there is a long list of things that the

Pediatric Consortium, the Alliance for Pediatric Therapies, that all your state organizations are working on. they just, you know, when they ask for help, I say, please give it. It's free to help. ⁓ And this really does benefit you guys in the long term, which we found out last year. So.

Jon Edenfield (16:23)
Well,

and shout out to you. Thank you so much for helping to get the word out there to other providers and helping us circulate that information. We appreciate you very much, Aaron.

Aaron Marshall (16:33)
My pleasure. It's my pleasure and impacts my clients as well. So it's huge. So I appreciate you guys. Thank you again for taking the time to meet with us. ⁓ You know, it's maybe this lasted a little bit longer than I advertised, but this is all gold and we're to get this up and make sure that you guys get some significant response to that survey. So thank you.

Jon Edenfield (16:56)
Sounds good. Thanks, Aaron.

Tara Hawkins (16:57)
Thank you.

Aaron Marshall (16:58)
Alright guys, have a great one!