Mental health services for Miami-Dade seniors in jeopardy after Florida healthcare agency changes billing practices

By Francisco Alvarado, FloridaBulldog.org

Miami-Dade senior citizens with mental health illnesses who rely on Medicaid and Medicare to cover their therapy sessions and medications are on the brink of losing their treatment thanks to the Florida Agency for Health Care Administration.

The agency, known as AHCA, stopped making Medicare and Medicaid payments directly to mental health clinics in July, requiring them to instead bill their clients’ private insurance companies for services. The change has thrown dozens of Miami-Dade community health providers into a tailspin.

Private insurers are either not approving them as providers or taking several months to authorize treatments for clients, mental health clinic owners claim. And when the services are approved, private insurers are taking a long time to pay the reimbursements, they said.

Yanet Avila, CEO of Doral’s Avila Health Group, told Florida Bulldog she’s been forced to whittle down her client base from 138 people to 40. “The whole process is messed up,” Avila said. “Out of 20 insurance companies, I was lucky enough to get one contract which is keeping my business afloat.”

Her clinic is also providing treatment to some of her remaining clients on a pro bono basis, Avila added. Among them is Mercedes Garcia Ferre, a 72-year-old Miami Gardens resident who told Florida Bulldog that she suffers from anxiety and depression. “In September, when they told me I wasn’t approved, I suffered a panic attack,” Ferre said. “I cried a lot and I was in bad shape. This situation with Medicaid and Medicare left me very frustrated.”

Avila said her clinic has continued to provide Ferre with therapy sessions because of serious concerns she has about the elderly woman’s mental health. “There was a point I was going to tell her and a bunch of other clients that I couldn’t hold on to all of them,” Avila said. “I thought I was about to close down.”

In an email statement, an AHCA spokesperson said private insurance companies are responsible for providing and arranging for Medicare and Medicaid benefits that mental health clients are entitled to receive. “Providers not currently within a [private insurance] network should work with participating plans,” the statement said. “Providers having difficulty joining a network may also contact the agency for additional assistance.”

SOME HELP FROM MIAMI-DADE SENATORS

According to seven emails obtained by Florida Bulldog, some clinic owners and mental health providers reached out to South Florida Republican State Sens. Manny Diaz Jr. and Ileana Garcia, both of whom sit on the Florida Senate Health Policy Committee, in August and in September when the private insurers were not approving them as providers. The clinic owners claim legislative assistants for the two Miami-Dade legislators did not follow up to set up meetings.

In a Sept. 28 response to one of the emails, Diaz’s executive secretary, Keanu Orfano, told a Miami physician’s assistant that he would speak to the senator about coordinating a meeting. The physician’s assistant, who asked to remain anonymous because he fears retaliation by AHCA, said Orfano never got back to him.

“We tried to get meetings with Diaz and Garcia multiple times and got no acknowledgement,” the physician’s assistant said. “It was a complete rejection and dismissal. It’s very disappointing since we are presenting a very significant problem in our community, especially for the elderly.”

A spokesperson for Diaz said he was on vacation for the holidays and unavailable for comment. Diaz, who is chairman of the health policy committee, also did not respond to a voicemail left on his cellphone.

In a phone interview, Garcia said her staff contacted AHCA officials in the agency’s Miami office after receiving the emails. The AHCA officials told her that they reached out to the mental health providers and requested documentation about their problems but received no answers.” Garcia said she spoke with AHCA officials on Wednesday who informed her the change in the reimbursement policy was done to reduce a high level of fraud in mental health billing.

“I am not sure it’s the right solution,” Garcia said. “I have asked AHCA to look into the reimbursement rates and the disruption of services to people who are in need. They have agreed to do both and the Florida Senate will stay on top of the progress.”

Meanwhile, some mental health providers are either closing up shop or considering shutting down their practices, the physician’s assistant said. “We’ve been covering expenses out of pocket,” the physician’s assistant said. “Many treatment centers have closed already. And many more will close soon.”

The physician’s assistant said he oversees a Miami mental health clinic with 1,000 clients that had to close for a week. “It is impossible for us to stay open and provide staff even if we wanted to,” the physician’s assistant said. “I am still working because of my ethical principles. I am hoping that eventually the insurance companies come to their senses and approve our contracts.”

WHERE’S THE FEDERAL FUNDING?

During the most recent legislative session, the Florida Legislature approved AHCA accessing $24.9 million from the federal Medicare Trust Fund to cover community mental health services. The coverage is contingent on the availability of $9.3 million in state matching funds, but the Legislature authorized AHCA to seek a federal waiver or a state plan amendment to implement the funding.

To find out if AHCA followed through, Jack Cory, a lobbyist for a group of community health providers, submitted a public records request to Mary Gay Templeton, executive assistant for the agency’s general counsel, on Dec. 13 requesting all documents showing the agency sought a federal waiver or a state plan amendment.

In a Dec. 20 response, Templeton’s office asserted that AHCA was not required to seek the waiver or implement an amendment. “The agency determined that [the] services are covered through the rehabilitative service descriptions in the Florida Medicaid State Plan,” the response states. “To this effect, the need to pursue a waiver or amendment is not necessary. Accordingly, there is no documentation pertaining to the agency seeking a waiver or amendment.”

In its statement to Florida Bulldog, AHCA’s spokesperson said the language in the General Appropriations Act has been implemented. However, the agency did not respond to questions about whether it has received the $24.9 million and if any of those funds have been disbursed for mental health services reimbursements.

“We are finding out now that insurance companies are not receiving funds to cover our services,” the physician’s assistant said. “And that is the primary reason they are flat out denying us. This is going to put a lot of patients at risk.”

Ferre, the Avila Health Group client, said she is worried that she will lose her treatment if the clinic doesn’t start getting reimbursed soon. “They are taking too long to approve treatment for senior citizens like me,” Ferre said. “We shouldn’t be in this position. It’s not positive for our mental state.”