Florida Doctors' Group Accuses Prominent Medicaid Operator of Delayed Payments
Certain bills have been pending for two years, leading doctors to express concerns about their ability to meet payroll and contemplate the possibility of no longer accepting Medicaid patients.
TroibNews 
TALLAHASSEE, Florida — A financial conflict involving hundreds of Florida’s most vulnerable children has arisen due to ongoing disputes over payments between doctors and the state's predominant Medicaid provider.
Physicians part of Privia Medical Group, a healthcare network operating out of Virginia with services across Florida, claim they are owed $781,000 by Sunshine State Health Plan, the state's leading Medicaid managed care plan.
The owed payments, some pending for over two years, have pushed the physicians to the brink, with concerns about covering payroll expenses and continuing to accept Medicaid patients in a state where nearly half of all children are insured under this low-income program.
“It's tough if you’re the only one in that area of the county that will take Medicaid,” said Tara Forcier, a pediatrician based in Brevard County, during a phone interview. “But what else can you do if you just can’t do it?”
A spokesperson for Sunshine has refuted claims of delayed payments, insisting that the company is committed to resolving billing disagreements swiftly.
The pediatricians reported their payment issues to Sunshine around June 2022, which initiated multiple meetings with promises to settle the growing debts, according to Forcier. Subsequently, more physicians outside Privia joined their efforts after seeing no progress with either Sunshine or the Florida Agency for Health Care Administration (AHCA).
Later, following enquiries by PMG to AHCA regarding the outstanding claims, progress was noted with reductions in the due amount by mid-August, Forcier noted. However, there remain disputes concerning interest on the $781,000 debt. Privia supports its network doctors by offering several services and has set up a loan fund for advancing payments delayed by Sunshine.
Lyndsey Brzozowski, a spokesperson for Sunshine, wrote in a statement, “When we learn of a claim or incentive payment issue, our team works to address and resolve them in a timely fashion.”
Despite this, frustrations remain for Forcier and her colleagues. "It never should have gotten to that point," Forcier remarked. “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’s spokesperson, Alecia Collins, has claimed that the issue was resolved expediently once it was brought to their attention and that Sunshine had settled the debts 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 stated, further noting that the dismissal was based on Sunshine Health’s report of the resolved payment.
Forcier’s documentation includes two years of emails and communications that depict a pattern of denied or unfulfilled payments from Sunshine, countering AHCA’s position. “It’s misleading to say we haven’t contacted the agency when we have evidence of those communications,” she said.
The potential regulatory and financial repercussions for Sunshine are significant, highlighted by their checkered history with AHCA, including heavy fines for compliance breaches. The company has recently managed to secure a contract with AHCA to serve in nine regions of the state for another six years, despite past issues.
Reflecting on the toll these challenges have taken, Forcier expressed concerns about the sustainability of serving a high number of Medicaid patients, given the financial instabilities caused by these delays.
“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,” said Forcier. “We take care of kids throughout the county, and having to shut down care for certain segments doesn't feel right.”As the situation unfolds, the implications of the financial disagreements between Privia Medical Group physicians and Sunshine State Health Plan extend beyond just the immediate financial impact. The uncertainty surrounding payments threatens the stability of practices serving children in need of Medicaid coverage, and it raises broader concerns about the capacity of Florida's healthcare system to provide necessary services for low-income families.
Pediatricians like Forcier express that they feel a moral obligation to care for their patients, despite the financial burden that these delays impose. Many of these children rely on government assistance for their healthcare needs, and for some families, losing access to a trusted physician could lead to significant health consequences. "It's not just about the money; it's about the care we provide," Forcier emphasized, acknowledging that every day spent in limbo adds another layer of stress for both medical providers and families.
The larger context reveals systemic issues within Florida's Medicaid managed care program. With approximately 3 million recipients enrolled, the strain on providers is exacerbated by administrative complexities and a lack of oversight. Experts have raised concerns about the capacity of AHCA to adequately monitor and regulate the operators, especially when the agency relies heavily on self-reported data from those operators about their compliance and claims processing.
As pressure mounts, there is a clear call for reform and greater accountability in the Medicaid system. Advocates argue for more transparent management practices and timely payments to prevent situations like these from recurring. "Changes need to be made at the administrative level to ensure that providers are supported and that children receive the care they need without disruption," Forcier said, emphasizing the need for reform to protect vulnerable populations.
In light of this ongoing dispute, some pediatricians are now considering diversification of their patient mix, while others are exploring alternative funding opportunities to stabilize their practices. These challenges prompt discussions surrounding the sustainability and management of Medicaid contract relationships in Florida, as well as the necessary systemic changes to secure adequate healthcare provision for families relying on Medicaid services.
Additionally, as the term of the current contracts approaches, there remains uncertainty about the potential for future negotiations between Sunshine and healthcare providers. The stakes are high, and for many families and providers, the implications of these decisions will extend well beyond financial considerations—they will affect the health and well-being of children across the state.
In the face of adversity, pediatricians like Forcier are committed to advocating for their patients and pressing for accountability in the Medicaid program. "We cannot shy away from these issues, as difficult as they may be," she outlined. "It's essential for the health of our communities that we ensure all children have access to care without arbitrary barriers."
As Florida’s Medicaid system grapples with these complexities, the resolution of this dispute holds the potential to shape the future of healthcare access for the state’s most vulnerable populations, reinforcing the importance of ongoing dialogue and collaboration between providers and state agencies to enhance care delivery. The hope is that through concerted efforts, the challenges faced today will pave the way for a more sustainable and equitable healthcare landscape in Florida.
James del Carmen for TROIB News
Physicians part of Privia Medical Group, a healthcare network operating out of Virginia with services across Florida, claim they are owed $781,000 by Sunshine State Health Plan, the state's leading Medicaid managed care plan.
The owed payments, some pending for over two years, have pushed the physicians to the brink, with concerns about covering payroll expenses and continuing to accept Medicaid patients in a state where nearly half of all children are insured under this low-income program.
“It's tough if you’re the only one in that area of the county that will take Medicaid,” said Tara Forcier, a pediatrician based in Brevard County, during a phone interview. “But what else can you do if you just can’t do it?”
A spokesperson for Sunshine has refuted claims of delayed payments, insisting that the company is committed to resolving billing disagreements swiftly.
The pediatricians reported their payment issues to Sunshine around June 2022, which initiated multiple meetings with promises to settle the growing debts, according to Forcier. Subsequently, more physicians outside Privia joined their efforts after seeing no progress with either Sunshine or the Florida Agency for Health Care Administration (AHCA).
Later, following enquiries by PMG to AHCA regarding the outstanding claims, progress was noted with reductions in the due amount by mid-August, Forcier noted. However, there remain disputes concerning interest on the $781,000 debt. Privia supports its network doctors by offering several services and has set up a loan fund for advancing payments delayed by Sunshine.
Lyndsey Brzozowski, a spokesperson for Sunshine, wrote in a statement, “When we learn of a claim or incentive payment issue, our team works to address and resolve them in a timely fashion.”
Despite this, frustrations remain for Forcier and her colleagues. "It never should have gotten to that point," Forcier remarked. “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’s spokesperson, Alecia Collins, has claimed that the issue was resolved expediently once it was brought to their attention and that Sunshine had settled the debts 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 stated, further noting that the dismissal was based on Sunshine Health’s report of the resolved payment.
Forcier’s documentation includes two years of emails and communications that depict a pattern of denied or unfulfilled payments from Sunshine, countering AHCA’s position. “It’s misleading to say we haven’t contacted the agency when we have evidence of those communications,” she said.
The potential regulatory and financial repercussions for Sunshine are significant, highlighted by their checkered history with AHCA, including heavy fines for compliance breaches. The company has recently managed to secure a contract with AHCA to serve in nine regions of the state for another six years, despite past issues.
Reflecting on the toll these challenges have taken, Forcier expressed concerns about the sustainability of serving a high number of Medicaid patients, given the financial instabilities caused by these delays.
“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,” said Forcier. “We take care of kids throughout the county, and having to shut down care for certain segments doesn't feel right.”As the situation unfolds, the implications of the financial disagreements between Privia Medical Group physicians and Sunshine State Health Plan extend beyond just the immediate financial impact. The uncertainty surrounding payments threatens the stability of practices serving children in need of Medicaid coverage, and it raises broader concerns about the capacity of Florida's healthcare system to provide necessary services for low-income families.
Pediatricians like Forcier express that they feel a moral obligation to care for their patients, despite the financial burden that these delays impose. Many of these children rely on government assistance for their healthcare needs, and for some families, losing access to a trusted physician could lead to significant health consequences. "It's not just about the money; it's about the care we provide," Forcier emphasized, acknowledging that every day spent in limbo adds another layer of stress for both medical providers and families.
The larger context reveals systemic issues within Florida's Medicaid managed care program. With approximately 3 million recipients enrolled, the strain on providers is exacerbated by administrative complexities and a lack of oversight. Experts have raised concerns about the capacity of AHCA to adequately monitor and regulate the operators, especially when the agency relies heavily on self-reported data from those operators about their compliance and claims processing.
As pressure mounts, there is a clear call for reform and greater accountability in the Medicaid system. Advocates argue for more transparent management practices and timely payments to prevent situations like these from recurring. "Changes need to be made at the administrative level to ensure that providers are supported and that children receive the care they need without disruption," Forcier said, emphasizing the need for reform to protect vulnerable populations.
In light of this ongoing dispute, some pediatricians are now considering diversification of their patient mix, while others are exploring alternative funding opportunities to stabilize their practices. These challenges prompt discussions surrounding the sustainability and management of Medicaid contract relationships in Florida, as well as the necessary systemic changes to secure adequate healthcare provision for families relying on Medicaid services.
Additionally, as the term of the current contracts approaches, there remains uncertainty about the potential for future negotiations between Sunshine and healthcare providers. The stakes are high, and for many families and providers, the implications of these decisions will extend well beyond financial considerations—they will affect the health and well-being of children across the state.
In the face of adversity, pediatricians like Forcier are committed to advocating for their patients and pressing for accountability in the Medicaid program. "We cannot shy away from these issues, as difficult as they may be," she outlined. "It's essential for the health of our communities that we ensure all children have access to care without arbitrary barriers."
As Florida’s Medicaid system grapples with these complexities, the resolution of this dispute holds the potential to shape the future of healthcare access for the state’s most vulnerable populations, reinforcing the importance of ongoing dialogue and collaboration between providers and state agencies to enhance care delivery. The hope is that through concerted efforts, the challenges faced today will pave the way for a more sustainable and equitable healthcare landscape in Florida.
James del Carmen for TROIB News
