In Florida, 37.9% of prescriptions were submitted to pharmacies electronically during the 1st quarter of 2012. The 37.9% e-prescribing rate achieved 106% of Florida's 35.9% projected benchmark for the 1st quarter of 2012. Quarterly projected benchmarks are determined by assuming a uniform rate of increase across four calendar quarters using the 2011 4th quarter 33.2% e-prescribing rate and the projected 2012 4th quarter 44% e-prescribing rate.
"Activated" means that pharmacies are connected to an e-prescribing network and are able to transmit e-prescriptions.
"Active Electronic Prescribers" means prescribers who have transmitted at least one e-prescription within the quarter.
"Not Ready" means that the application requires further action by the applicant before it can be reviewed by state staff.
"Not Ready" means that the application requires further action by the applicant before it can be reviewed by state staff.
Cumulative hospital incentives paid to date.
Cumulative provider incentives paid to date.
This chart shows the number of ambulatory surgery center adverse incidents by type and by quarter.
TERM DEFINITION
Adverse Incidents Adverse incidents are medical incidents defined in section 395.0197, Florida Statutes. They include the following types of incidents; wrong site surgery, wrong patient surgery, wrong surgical procedure, patient death, brain or spinal damage to a patient, and removal of unplanned foreign objects remaining from a surgical procedure. Hospitals and ambulatory surgical centers are required by law to report adverse incidents to the Agency.
This chart shows the number of hospital adverse incidents, by type and by quarter.
TERM DEFINITION
Adverse Incidents Adverse incidents are medical incidents defined in section 395.0197, Florida Statutes. They include the following types of incidents; wrong site surgery, wrong patient surgery, wrong surgical procedure, patient death, brain or spinal damage to a patient, and removal of unplanned foreign objects remaining from a surgical procedure. Hospitals and ambulatory surgical centers are required by law to report adverse incidents to the Agency.
This chart shows the number of assisted living facility adverse incidents by type and quarter.
This chart shows the number of nursing home adverse incidents by type and quarter.
Complaints about care in healthcare facilities are received by the Agency for Health Care Administration Complaint Administration Unit either by e-mail, phone, or mail. Once received, the information is prioritized as to the severity of the allegations in the complaint and the information is entered into the Agency?s database. The complaint is forwarded to the Field Office where the facility is located so that surveyors in that area can plan to do a survey. There may be a lag time between the date the complaint is received and the survey date due to the prioritization of the complaint. During the survey, the surveyors read the patient charts, observe the patient care, and speak with the staff who are providing the care. After the information is gathered, the surveyor makes the determination if the facility has engaged in deficient practice by violating regulations. If the determination is made that indeed the facility has engaged in deficient practice, the complaint has been confirmed.
The Call Center (also known as the Consumer Hot Line) shows this measure in the column marked Average Speed to Answer. Once the caller chooses an option (1 through 5) from those on the response line, the computerized telephone system measures the length of time it takes, in seconds, to reach a live person. This measure is derived by dividing the total seconds for all calls answered by the total number of calls answered. The average speed to answer should not exceed 60 seconds.
TERM DEFINITION
Calls Abandoned Calls waiting in queue before reaching a live operator that never get through to a live operator. The caller may disconnect the call or some system interruption may occur to prevent completion. The percentage of abandoned calls should not exceed 5% of the total calls received.
The Call Center is the intake point for complaint calls about health care facilities. It also provides information, distributes requested publications and provides complaint forms for consumer use on health care practitioners regulated by the Department of Health.
TERM DEFINITION
Calls Abandoned Calls waiting in queue before reaching a live operator that never get through to a live operator. The caller may disconnect the call or some system interruption may occur to prevent completion. The percentage of abandoned calls should not exceed 5% of the total calls received.
Number of calls received by AHCA Complaint and Information Call Center
The amount of money the vendor for the AHCA Complaint & Information Call Center was sanctioned due to not meeting performance measures.
When a person or entity applies to the Agency to receive a license under Chapter 408, Florida Statutes, the Agency must approve or deny licensure within 60 days of the date the application is deemed complete. An application is complete when all required documentation is received by the Agency, or if required, upon successful completion of a survey. The measure reflects the average time it takes for the agency to approve or deny licensure following completion of the application. Application decisions reported here were made during the previous three month period.
When a person or entity applies to the Agency to receive a license under Chapter 408, Florida Statutes, the Agency must approve or deny licensure within 60 days of the date the application is deemed complete. An application is complete when all required documentation is received by the Agency, or if required, upon successful completion of a survey. For initial, renewal and change of ownership applications completed during the previous three month period, the chart shows the percent of applications that were incomplete due to missing documentation, cases resulting from a failure to submit missing documentation timely, and the percent requiring and inspection. These are the responsibility of the applicant.
When a person or entity applies to the agency to receive a license under Chapter 408, Florida Statutes, the agency must examine the application and, within 30 days after receipt, notify the applicant in writing of any apparent errors or omissions and request any additional information required. Additionally, the agency must approve or deny licensure within 60 days of the date the application is deemed complete. An application is complete when all required documentation is received by the agency, or if required, upon successful completion of a survey. For initial, renewal and change of ownership applications completed during the previous three month period, the chart shows the average number of days to send the omission letter, to complete the application and to make the decision to approve or deny licensure. The segments shown in blue and yellow represent time spent by Agency staff to review, omit and approve or deny the application. The segments shown in red reflect time spent by the applicants to respond to the omissions letter and complete the necessary steps in the process.
The Division of Health Quality Assurance is charged with licensure/registration of health care service providers, including hospitals, nursing homes, assisted living facilities, and home health agencies, to name a few. This chart shows the number of initial, renewal and change of ownership licensure applications received by the units during the prior three months.
This chart shows the number of correspondence and public information requests completed by each unit during the prior twelve month period.
Clinical assessment coding questions and technical support questions about Minimum Data Set (MDS) and Outcome and Assessment Information Set (OASIS) are received by the Agency for Health Care Administration MDS/OASIS Help Desk staff either by e-mail, phone, fax, or mail. Once received, the Help Desk staff collects information in a database and responds to the provider in the order the inquiry was received. If the issue is not under the Agency's authority, the caller is forwarded to the appropriate Centers for Medicare and Medicaid Services (CMS) contractor for resolution. During the troubleshooting process, the MDS/OASIS support staff read validation reports, CASPER reports, data submission files, CMS resources, manuals and data specifications in order to provide responses consistent with the MDS and OASIS program requirements. After the information is gathered, our support staff are able to assist the facility with clinical and automation compliance. On occasion, questions are forwarded to CMS and/or their subcontractors for clarification. There may be a lag time between the date the inquiry is received and the date resolved due to spikes in call volume and resolution complexity.
Home health agencies are required by the Centers for Medicare and Medicaid Services (CMS) to demonstrate compliance with the OASIS Test transmission prior to being scheduled for an initial certification survey by either an accreditation organization or the state survey agency. The MDS/OASIS Help Desk staff provide technical support for this test transmission requirement. Test accounts are issued based upon the availability of a limited number of login IDs, workload, and/or the need to coordinate with accrediting organizations; therefore, there can be a lag between the home health agency's request date and issuance date. Home health agencies are first directed to complete the Recommended Steps for Obtaining a Florida OASIS Test Account. This document is meant to ensure the home health agency is actually ready to conduct the test transmission when the test account is requested. Once a test account is issued to the provider they are granted one week to complete a successful transmission. However, it can take several lengthy one-on-one communications and a significant amount of time with the home health agency staff to explain the process, and troubleshoot configuration and submission problems. Upon completion of a successful test submission, the MDS/OASIS Help Desk staff issue G325 compliance letters to successful providers once a week. This dashboard measure reports the number of G325 compliance letters issued to home health agencies each month.
The chart above represents dollars sanctioned versus dollars collected from the Medicaid Managed Health Care Plans by fiscal year (FY). Most of the big sanctions were for Marketing violations. Marketing was prohibited by contract in early 2009, so you will see that the sanction dollar amounts drop drastically. The reason for the wide variances is due to the settlement agreement for previous Marketing sanctions levied against HealthEase and Staywell imposed over 3 years, which were collected by the Agency for Health Care Administration in the amount of $500,000 during FY 08/09.
TERM DEFINITION
Managed Health Care Plan A health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized by Medicaid, or an exclusive provider organization certified under s. 627.6472.
The turnaround time is based on the time it takes from receipt to resolution of all managed health care plan complaints. These complaints include only those which were resolved by units within the Bureau of Managed Health Care (BMHC) and do not include complaints referred outside the BMHC for closure. The average number of days reflects the cumulative number of calendar days to resolve complaints divided by the number of complaints resolved. The BMHC is expected to process 90% of its complaints within 5 business days. This chart identifies the total number of complaints resolved per month and how many were resolved within the specified goal of 5 business days.
TERM DEFINITION
Managed Health Care Plan A health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized by Medicaid, or an exclusive provider organization certified under s. 627.6472.
Neglect Failure to provide care and services.
Subscriber An individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.
The turnaround time is based on the time it takes from receipt to resolution of all managed health care plan complaints. These complaints include only those which were resolved by staff in units within the Bureau of Managed Health Care (BMHC) and do not include complaints referred outside the BMHC for closure. The average number of days reflects the cumulative number of calendar days to resolve complaints divided by the number of complaints resolved. The BMHC is expected to process 90% of its complaints within 5 business days.
The chart above represents the total number of desk reviews from all units within the Bureau of Managed Health Care (BMHC) for Medicaid Managed Health Care Plans within the specified timeframe. A desk review is when the BMHC Analyst approves (or denies) contractual issues submitted by the Medicaid Managed Health Care Plans. Some examples would be the review of policies and procedures, community outreach material (which includes public service announcements and forms of advertising), material to be sent to enrollees and providers, etc. The BMHC's internal goal is to complete 100% of all desk reviews within 15 days of receipt. (It should be noted that the numbers for July represent completion of desk reviews within 10 days of receipt.)
TERM DEFINITION
Managed Health Care Plan A health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized by Medicaid, or an exclusive provider organization certified under s. 627.6472.
Neglect Failure to provide care and services.
Subscriber An individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.
By Florida statute, the Office of Plans and Construction has 60 days to complete each facility construction plan review that is submitted. This measure is the percentage of Stage 1, Schematic Reviews, and Stage 2, Preliminary Reviews completed within the required 60 day time frame for each month of the year from July 1, 2011 through June 30, 2012. The data for this measure is obtained from the Office of Plans and Construction tracking program.
TERM DEFINITION
Office of Plans and Construction The Office of Plans and Construction is required by Florida statute to review the plans and construction of hospitals, nursing homes, ambulatory surgical centers, and intermediate care facilities for the developmentally disabled. If requested by the provider, the Office of Plans and Construction is permitted by Florida statute to review the plans and construction of inpatient hospice facilities and assisted living facilities.
By Florida statute, the Office of Plans and Construction has 60 days to complete each facility construction plan review that is submitted. This measure is the percentage of Stage 3, Construction Document Reviews and Revised Construction Document Reviews completed within the required 60 day time frame for each month from July 1, 2011 through June 30, 2012. The data for this measure is obtained from the Office of Plans and Construction tracking program.
TERM DEFINITION
Office of Plans and Construction The Office of Plans and Construction is required by Florida statute to review the plans and construction of hospitals, nursing homes, ambulatory surgical centers, and intermediate care facilities for the developmentally disabled. If requested by the provider, the Office of Plans and Construction is permitted by Florida statute to review the plans and construction of inpatient hospice facilities and assisted living facilities.
By Florida statute, the Office of Plans and Construction has 60 days to complete each facility construction plan review that is submitted. This measure is a cumulative average of the number of calendar days required to complete all plan reviews(stage 1, stage 2 and stage 3 plan reviews) starting on July 1, 2011 with monthly additions through June 30, 2012. The data for this measure is obtained from the Office of Plans and Construction tracking program.
TERM DEFINITION
Office of Plans and Construction The Office of Plans and Construction is required by Florida statute to review the plans and construction of hospitals, nursing homes, ambulatory surgical centers, and intermediate care facilities for the developmentally disabled. If requested by the provider, the Office of Plans and Construction is permitted by Florida statute to review the plans and construction of inpatient hospice facilities and assisted living facilities.
This measure records the total number of plans reviewed that have to be completed each month. This number includes all of the Stage 1 schematic reviews, Stage 2 preliminary and revised preliminary reviews, and all stage 3 reviews including construction document reviews, revised construction document reviews, early permit reviews and desk reviews. The data for this measure is obtained from the Office of Plans and Construction tracking program.
TERM DEFINITION
Office of Plans and Construction The Office of Plans and Construction is required by Florida statute to review the plans and construction of hospitals, nursing homes, ambulatory surgical centers, and intermediate care facilities for the developmentally disabled. If requested by the provider, the Office of Plans and Construction is permitted by Florida statute to review the plans and construction of inpatient hospice facilities and assisted living facilities.
Priority 1 Complaints are those complaints against health care facilities that allege potential or actual serious injury, harm, impairment, or death to a resident. These are crisis situations in which the health and safety of individuals are at risk. The Area Offices are expected to survey the facilities that receive these complaints within 2 business days of assignment. Examples of Priority 1 complaints include, but are not limited to those that allege:
The Subscriber Assistance Program (Program) provides a review of grievances that remain unresolved after the completion of a managed health care plan's entire grievance process. The Program's turnaround time is based on the time it takes from receipt to resolution of all subscriber grievances, including those that are outside of the Program's jurisdiction. The average number of days reflects the cumulative number of calendar days to process cases divided by the number of grievances resolved. State law requires us to complete our grievance process within 165 days after a grievance is filed with the Program. Currently, the average time for completion of the process is considerably less. State law also requires that the Program review all grievances within 60 days after receipt and that the Subscriber Assistance Panel (Panel) hear the grievance no later than 120 days after the date the grievance was filed. The Program's internal performance standard is to have a grievance reviewed, prepared and heard by the Panel within 60 days after a grievance is filed with the Program.
TERM DEFINITION
Grievance An appeal by a subscriber of an organizational decision made by the health plan that affects the subscriber.
Managed Health Care Plan A health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized by Medicaid, or an exclusive provider organization certified under s. 627.6472.
Subscriber An individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.
Subscriber Assistance Program The program required by section 408.7056, Florida Statute, to provide assistance to subscribers, including those whose grievances are not resolved by the managed care entity to the satisfaction of the subscriber. The program consists of panels of appointees from the Agency, the Department of Financial Services and the Governor's Office that meet as often as necessary to timely review, consider, and hear grievances and recommend any actions that should be taken concerning individual cases.
The Subscriber Assistance Program (Program) provides a review of grievances that remain unresolved after the completion of a managed health care plan's entire grievance process. The number of cases received reflects all incoming requests for assistance. OOJ cases represent the grievances determined to be out of the Program¿s jurisdiction. Grievance found in favor of the Subscriber prior to a Subscriber Assistance Panel (Panel) hearing reflect the number of resolved cases. Lastly, heard cases are those that go to a Panel hearing during the specified timeframe.
The Subscriber Assistance Program (Program) provides a review of grievances that remain unresolved after the completion of a managed health care plan's entire grievance process. The outcomes above represent all cases this fiscal year that were either heard by the Subscriber Assistance Panel (Panel) or resolved in favor of the subscriber by Program staff prior to a Panel hearing.
TERM DEFINITION
Grievance An appeal by a subscriber of an organizational decision made by the health plan that affects the subscriber.
Managed Health Care Plan A health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized by Medicaid, or an exclusive provider organization certified under s. 627.6472.
Subscriber An individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.
Subscriber Assistance Program The program required by section 408.7056, Florida Statute, to provide assistance to subscribers, including those whose grievances are not resolved by the managed care entity to the satisfaction of the subscriber. The program consists of panels of appointees from the Agency, the Department of Financial Services and the Governor's Office that meet as often as necessary to timely review, consider, and hear grievances and recommend any actions that should be taken concerning individual cases.
The Subscriber Assistance Program provides an external review of grievances that remain unresolved after the completion of a managed health care plan's entire grievance process. The graph above reflects the managed health care plan's basis of denial during its internal grievance process for all cases which were either heard by the Panel or resolved in the Subscriber's favor prior to a Panel hearing within the specified timeframe.
TERM DEFINITION
Grievance An appeal by a subscriber of an organizational decision made by the health plan that affects the subscriber.
Managed Health Care Plan A health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized by Medicaid, or an exclusive provider organization certified under s. 627.6472.
Subscriber An individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.
Subscriber Assistance Program The program required by section 408.7056, Florida Statute, to provide assistance to subscribers, including those whose grievances are not resolved by the managed care entity to the satisfaction of the subscriber. The program consists of panels of appointees from the Agency, the Department of Financial Services and the Governor's Office that meet as often as necessary to timely review, consider, and hear grievances and recommend any actions that should be taken concerning individual cases.
Health Quality Assurance/Field Operations Surveyors have implemented a new survey process for Ambulatory Surgical Centers (ASCs) that targets breaches in infection control in these facilities. The process was developed by the Centers for Medicare and Medicaid Services. They offered the State Agencies an opportunity to claim economic recovery funds to survey more ambulatory surgical centers than were allotted in the regular budgets. Florida State Agency is required to survey 46 facilities in the regular Survey and Certification Budget Grant. An additional grant of $460,273.00 has been provided through economic recovery funds for additional surveys. As of July 31, 2010, fifty (50) additional surveys have been completed.
Among the prevention activities engaged in by Medical Program Integrity are the use of prepayment reviews to identify improper claims and deny payment. A Provider must submit supporting documentation for claims under prepayment review so that MPI can determine whether to pay or deny the claim. In prepayment review, claims not having proper documentation are denied.
TERM DEFINITION
Denied Claim A claim that was submitted for payment that was later deemed unsuitable for payment due to insufficient documentation.
Fiscal Year The fiscal year is a 12-month period (from July 1 - June 30) of any given year.
Fraud and Abuse A deception deliberately practiced in order to secure unfair or unlawful gain within the Medicaid program. The most common involves doctors, dentists, clinics and other health care providers billing for services never performed, over billing for services provided, or billing for tests, services and products which are medically unnecessary.
MPI The Bureau of Medicaid Program Integrity audits and investigates providers suspected of overbilling or defrauding Florida's Medicaid program, recovers overpayments, issues administrative sanctions, and refers cases of suspected fraud for criminal investigation.
In some circumstances, the agency has discretion to, and in others must, impose a sanction against a person, provider or entity, for failure to comply with Medicaid laws, rules or policies. Sanctions may vary significantly, depending on the nature and seriousness of the violation. See individual Medicaid Sanctioned Providers by following the "Download Details" link above and following instructions provided in the document.
TERM DEFINITION
CAP Corrective Action Plan - The process or plan by which the provider will ensure future compliance with state and federal Medicaid laws, the laws that govern the provider's profession, or the Medicaid provider agreement.
Fine A monetary sanction.
Medicaid The state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children.
Suspension A one-year preclusion from any action that results in a claim for payment to the Medicaid program as a result of furnishing, supervising a person who is furnishing, or causing a person to furnish goods or services.
Termination A twenty-year preclusion from any action that results in a claim for payment to the Medicaid program as a result of furnishing, supervising a person who is furnishing, or causing a person to furnish goods and services.
Among the prevention activities engaged in by Medical Program Integrity are the use of prepayment reviews to identify improper claims and deny payment. A Provider must submit supporting documentation for claims under prepayment review so that MPI can determine whether to pay or deny the claim. In prepayment review, claims not having proper documentation are denied.
TERM DEFINITION
Denied Claim A claim that was submitted for payment that was later deemed unsuitable for payment due to insufficient documentation.
Fraud and Abuse A deception deliberately practiced in order to secure unfair or unlawful gain within the Medicaid program. The most common involves doctors, dentists, clinics and other health care providers billing for services never performed, over billing for services provided, or billing for tests, services and products which are medically unnecessary.
Intercepted Payments Medicaid claims that have been processed for payment but the payment has not yet been sent to the provider.
MPI The Bureau of Medicaid Program Integrity audits and investigates providers suspected of overbilling or defrauding Florida's Medicaid program, recovers overpayments, issues administrative sanctions, and refers cases of suspected fraud for criminal investigation.
Pended Claims Claims that have not yet been processed for payment
Prepayment Review An examination of claims associated with "intercepted payments" and evaluation of "pended claims" for accuracy.
The Finance and Accounting bureau collects amounts identified as overpayments through either direct payments from providers or the withholding of Medicaid or Medicare payments. Recoveries also include the amounts recovered through Claims Reversals.
TERM DEFINITION
Collections The amount of money collected back from Medicaid Providers due to overpayment.
Fraud and Abuse A deception deliberately practiced in order to secure unfair or unlawful gain within the Medicaid program. The most common involves doctors, dentists, clinics and other health care providers billing for services never performed, over billing for services provided, or billing for tests, services and products which are medically unnecessary.
Recoveries The amounts recovered through Claims Adjustments and Claims Reversals.
Overpayments Identified includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claims, unacceptable practices, fraud, abuse or mistake.
TERM DEFINITION
Fraud and Abuse A deception deliberately practiced in order to secure unfair or unlawful gain within the Medicaid program. The most common involves doctors, dentists, clinics and other health care providers billing for services never performed, over billing for services provided, or billing for tests, services and products which are medically unnecessary.
Referrals are made to several agencies due to fraud and abuse issues as well as quality of care issues.
TERM DEFINITION
DOH Florida's Department of Health
FDLE Florida Department of Law Enforcement
HQA The Agency for Health Care Administration's Health Quality Assurance Bureau.
MFCU Medicaid Fraud Control Unit - The Medicaid Fraud Control Unit is part of the Attorney General's Office and shares the responsibility for policing Florida's $16 billion per year Medicaid program.
Medicaid The state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children.
Other Other oversight organizations outside of the agency to which referrals would be sent. e.g. Medicaid Contract Management, Pharmacy Services, Center for Medicare & Medicaid Services, Electronic Data Systems, Department of Children and Families, Department of Elder Affairs
Referral The act of notifying an outside agency of improper use of Medicaid. The referral will go do various outside agencies depending on the nature of the impropriety.
Referrals are made to several agencies due to fraud and abuse issues as well as quality of care issues.
TERM DEFINITION
DOH Florida's Department of Health
FDLE Florida Department of Law Enforcement
HQA The Agency for Health Care Administration's Health Quality Assurance Bureau.
MFCU Medicaid Fraud Control Unit - The Medicaid Fraud Control Unit is part of the Attorney General's Office and shares the responsibility for policing Florida's $16 billion per year Medicaid program.
Medicaid The state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children.
Other Other oversight organizations outside of the agency to which referrals would be sent. e.g. Medicaid Contract Management, Pharmacy Services, Center for Medicare & Medicaid Services, Electronic Data Systems, Department of Children and Families, Department of Elder Affairs
Referral The act of notifying an outside agency of improper use of Medicaid. The referral will go do various outside agencies depending on the nature of the impropriety.
The Area Offices routinely provide training to Medicaid Providers. This chart represents the satisfaction of Providers with Area Office training programs. The goal for this chart is the average satisfaction rating of 4.4
TERM DEFINITION
MedTel Track MedTelTrack is a Web-based telephone call tracking system accessible through the AHCA Intranet. Call data is input and shared by Medicaid Headquarters and the eleven Medicaid Area Offices. MedTelTrack was designed by the AHCA MIS Applications Group.
Medicaid Area Offices Medicaid has eleven Area Offices located throughout the state that represent a dynamic blend of divergent geographic, cultural, social and economic factors and conditions. They range in size from one county to 16 and serve more than 2.1 million Medicaid Beneficiaries. The Field Area Office functions and responsibilities fall into two major categories: Beneficiary/Network Management and Compliance/Quality Management. These functions provide local management of Provider networks and assist Beneficiaries to navigate the healthcare system.
Medicaid Providers Any person/group who has enrolled in the Florida Medicaid program to furnish medical care, services or supplies; or to arrange for the furnishing of such care, services or supplies; or to submit claims for such care, services or supplies for or on behalf of another person.
Provider Training Any scheduled training conducted with at least one staff from a Florida Medicaid Provider (or applicant for enrollment), which utilizes an existing Florida Medicaid training module/curriculum as it's core content. Technical assistance meetings, monitorings or visits are not included in these activities.
The number of calls received in the Medicaid Area Offices related to specialists. This does not indicate if these were calls for required access, complaints, compliments, specialist calling in for other reasons or other calls, just that the call was related to the category of specialty care.
This chart tracks the average number of days that sampled exceptional claims spend in-house, in the eleven Medicaid Area Offices per month. This indicator is measured to ensure timely claims processing in the Area Offices. The goal for this chart is not to exceed an average of 15 workdays per month.
TERM DEFINITION
Adjudication The System processing of a claim to determine if it pays or denies, or suspends
Claim A provider invoice/bill for services rendered to a Medicaid beneficiary
Claims This figure represents the number of calls from Providers and Recipients regarding the submission and processing of Medicaid claims for reimbursement. (Examples: To explain the general process of getting claims paid, to research and answer questions regarding specific claims that have not adjudicated, and questions about direct client reimbursement)
Denied Claim A claim that has been processed and did not pass all System audits and edits and is not reimbursable to the provider
Medicaid Area Offices Medicaid has eleven Area Offices located throughout the state that represent a dynamic blend of divergent geographic, cultural, social and economic factors and conditions. They range in size from one county to 16 and serve more than 2.1 million Medicaid Beneficiaries. The Field Area Office functions and responsibilities fall into two major categories: Beneficiary/Network Management and Compliance/Quality Management. These functions provide local management of Provider networks and assist Beneficiaries to navigate the healthcare system.
Medicaid Providers Any person/group who has enrolled in the Florida Medicaid program to furnish medical care, services or supplies; or to arrange for the furnishing of such care, services or supplies; or to submit claims for such care, services or supplies for or on behalf of another person.
Paid Claim A claim that has been processed and passed all System audits and edits and is reimbursable to the provider
Processed Claim A claim that has been adjudicated can be submitted by a provider, generated by the state (a HMO monthly capitation payment per beneficiary, or special reprocessing for corrections or legislative mandates), or provider claim voids and adjustments
The percent of MediPass PCP Re-credentialing packages mailed to Headquarters from the Area Offices each month, prior to the practice expiration date in Versa. The goal for this measure is to maintain a 90% or higher compliance rate each month. PLEASE NOTE: A 120-day period is allowed for the completion of a recredentialing. As a result, the Dashboard reflects the month the assignment was received in the Area Office, not the month of completion (e.g. September, 2010 Dashboard data will represent recredentialings assigned in September, with a competion due of January, 2011) .
TERM DEFINITION
MediPass/Managed Care This figure represents the number of calls with questions about MediPass, CMS, and Medicaid HMOs. (Examples: available Providers, differences between MediPass and Medicaid HMO, change in enrollment with Primary Care Provider)
Medicaid Area Offices Medicaid has eleven Area Offices located throughout the state that represent a dynamic blend of divergent geographic, cultural, social and economic factors and conditions. They range in size from one county to 16 and serve more than 2.1 million Medicaid Beneficiaries. The Field Area Office functions and responsibilities fall into two major categories: Beneficiary/Network Management and Compliance/Quality Management. These functions provide local management of Provider networks and assist Beneficiaries to navigate the healthcare system.
Medicaid Providers Any person/group who has enrolled in the Florida Medicaid program to furnish medical care, services or supplies; or to arrange for the furnishing of such care, services or supplies; or to submit claims for such care, services or supplies for or on behalf of another person.
This chart tracks the number of Provider and Beneficiary calls the eleven Medicaid Area Offices handle per month. Call volume is measured to indicate optimal call levels and peak volume. The goal for this chart is 55,000 logged calls.
TERM DEFINITION
MedTel Track MedTelTrack is a Web-based telephone call tracking system accessible through the AHCA Intranet. Call data is input and shared by Medicaid Headquarters and the eleven Medicaid Area Offices. MedTelTrack was designed by the AHCA MIS Applications Group.
Medicaid Area Offices Medicaid has eleven Area Offices located throughout the state that represent a dynamic blend of divergent geographic, cultural, social and economic factors and conditions. They range in size from one county to 16 and serve more than 2.1 million Medicaid Beneficiaries. The Field Area Office functions and responsibilities fall into two major categories: Beneficiary/Network Management and Compliance/Quality Management. These functions provide local management of Provider networks and assist Beneficiaries to navigate the healthcare system.
This chart breaks down the top 5 reasons people contact the Medicaid Field Offices. All other calls are grouped into the category Other.
TERM DEFINITION
Claims This figure represents the number of calls from Providers and Recipients regarding the submission and processing of Medicaid claims for reimbursement. (Examples: To explain the general process of getting claims paid, to research and answer questions regarding specific claims that have not adjudicated, and questions about direct client reimbursement)
Eligibility/File Maintenance This figure represents the number of calls with questions about Recipient Eligibility and/or Recipient Eligibility File Problems. (Examples: where to apply/reapply for Medicaid, how to get a gold card, how to check the status of application/change, where to submit documents/bills, questions about Medically Needy Program, client has been approved for Medicaid but not on file, gaps of coverage on recipients file, retroactive coverage not on file)
Health Systems Coordination and Navigation This figure represents the number of calls from Providers and Recipients on defined issues related to health systems. (Examples: access, advocacy, Third Party Liability, authorizations)
MediPass/Managed Care This figure represents the number of calls with questions about MediPass, CMS, and Medicaid HMOs. (Examples: available Providers, differences between MediPass and Medicaid HMO, change in enrollment with Primary Care Provider)
Medicaid Area Offices Medicaid has eleven Area Offices located throughout the state that represent a dynamic blend of divergent geographic, cultural, social and economic factors and conditions. They range in size from one county to 16 and serve more than 2.1 million Medicaid Beneficiaries. The Field Area Office functions and responsibilities fall into two major categories: Beneficiary/Network Management and Compliance/Quality Management. These functions provide local management of Provider networks and assist Beneficiaries to navigate the healthcare system.
Other This figure represents the number of calls from all other call types, not listed in the Top Five on the Area Office chart. These include; CALL ATTEMPT, COMPLAINT, ENROLLMENT/REENROLLMENT, FA TRANSITION, FRAUD, KIDCARE, MEDICAID REFORM, MEDICARE, MONITORING/QUALITY ASSURANCE, NETWORK SURVEY, PHARMACY AND TRAINING/OUTREACH.
Request for a Specialist This figure represents the number of calls from Providers and Recipients requesting assistance with locating a specialty provider.
This graph shows the actual Aged and Disabled population enrollment compared to the estimated caseload enrollment at the state Estimating Conference. Caseload is not controlled by Medicaid but is an indicator of many factors including the economy. Variance from estimate is tracked due to its effect on budget estimates.
TERM DEFINITION
Aged and Disabled aka Supplemental Security Income (SSI) SSI eligibility is determined by the federal Social Security Administration. All SSI recipients residing in Florida are automatically entitled to Florida Medicaid with full benefits.
Beneficiaries A person who receives Medicaid services.
Caseload The number of people enrolled in Medicaid.
Children and Family aka Temporary Assistance to Needy Families (TANF) These include all Medicaid programs with full benefits for children and families: Low income families; Medicaid Expansion Designated by SOBRA (MEDS); Public Medical Assistance (PMA); Foster Care, Adoption Subsidy, and Emergency Shelter. Also included are Medicaid programs with limited benefits for children and families: Emergency Medicaid for Aliens (EMA); Presumptively Eligible Pregnant Women (PEPW).
Estimating Conference The state of Florida utilizes a consensus process in developing many of the estimates of revenue and expenditures that are necessary for the preparation of the state budget. This consensus process is implemented through various Florida estimating conferences as specified in sections 216.133-137, Florida Statutes. Professional staff who have forecasting expertise from the Executive Office of the Governor, the Office of Economic and Demographic Research, the Senate and House of Representatives serve as conference principals. These principals must arrive at a consensus in order to have an official forecast or estimate. Once a forecast or estimate is adopted, it is used in all planning and budgeting actions of the state. The Social Services Estimating Conference is the format used to arrive at a consensus forecast of caseload, and funds needed, for Florida's Medicaid program. Medicaid estimates are developed as a two step process. Principals initially meet to reach consensus on caseload estimates. Subsequently, principals reconvene to reach consensus on funding needs based on the consensus caseloads. Estimating conferences are conducted twice a year. The first conference is usually held around the month of October, to establish a forecast for the next fiscal year's budget recommendations made by the Governor to the Legislature, and the next conference is conducted around the month of February to provide a closer estimate of current year Medicaid spending and appropriations needed during the upcoming legislative session.
Medicaid Eligibility For purposes of the Dashboard, Medicaid eligibility has been ?fit? into three categories, each of which is separately defined below: Supplemental Security Income, Temporary Assistance to Needy Families, and Other.
Other Medicaid Eligibility For purposes of the Dashboard, all other eligibles are grouped into an "other" category, which includes: Medicaid for the Aged and Disabled (MEDS-AD); the Refugee Program; Medically Needy; Qualified Medicare Beneficiaries (QMB); Special or Specified Low-Income Medicare Beneficiaries; Qualifying Individuals I (formerly PBMO), Part B Medicare Only (QI 1).
This graph shows the actual Children and Family population enrollment compared to the estimated caseload enrollment at the state Estimating Conference. Caseload is not controlled by Medicaid but is an indicator of many factors including the economy. Variance from estimate is tracked due to its effect on budget estimates.
This graph shows the actual "Other Categories of Eligibility" enrollment compared to the estimated caseload enrollment at the state Estimating Conference. Caseload is not controlled by Medicaid but is an indicator of many factors including the economy. Variance from estimate is tracked due to its effect on budget estimates.
Aged & Disabled Beneficiary Enrollment - Historical
Children & Families Beneficiary Enrollment - Historical
Other Eligibility Categories Beneficiary Enrollment Historical
Beneficiary Enrollment by Category
This graph shows the percentage of calls to the Choice Counseling toll-free number that were abandoned the previous month. The state requires that less than 5% of all calls received each month are abandoned.
This graph shows the percentage of Beneficiaries on hold for less than 180 seconds before they were connected to a Choice Counselor for the previous month. The state requires that 96% of beneficiaries who call are on hold for less than 180 seconds.
This graph shows the average number of minutes Choice Counselors spent talking with individuals who called the Choice Counseling toll-free number.
This graph shows the percentage of Beneficiaries on hold for less than 180 seconds before they were connected to a Choice Counselor for a 12 month period.
This graph shows the percentage of calls to the Choice Counseling toll-free number that were abandoned over a 12 months period.
TERM DEFINITION
Abandoned Call A call that is answered and the caller selects an option (such as language they speak) and is either not permitted access to that option or the caller disconnects from the call for any reason. The contract standard is that less than 5 percent of all calls can be abandoned in the month.
This graph shows the average number of minutes Choice Counselors spent talking with individuals who called the Choice Counseling toll-free number over a 12 month period.
Number of days from entry date to payment date. This represents how quickly a claim is adjudicated and paid by the various methods, paper, electronic and then the average of both methods.
TERM DEFINITION
Adjudication The System processing of a claim to determine if it pays or denies, or suspends
Claim A provider invoice/bill for services rendered to a Medicaid beneficiary
Paid Claim A claim that has been processed and passed all System audits and edits and is reimbursable to the provider
Number of paid claim lines.
TERM DEFINITION
Adjudication The System processing of a claim to determine if it pays or denies, or suspends
Claim A provider invoice/bill for services rendered to a Medicaid beneficiary
Claim Lines Individual billable claim lines on a claim form/record
Denied Claim A claim that has been processed and did not pass all System audits and edits and is not reimbursable to the provider
Paid Claim A claim that has been processed and passed all System audits and edits and is reimbursable to the provider
Number of days from entry date (of the claim entered into the system) to payment date - represents how quickly a claim is adjudicated and paid once entered into the system.
TERM DEFINITION
Adjudication The System processing of a claim to determine if it pays or denies, or suspends
Claim A provider invoice/bill for services rendered to a Medicaid beneficiary
Paid Claim A claim that has been processed and passed all System audits and edits and is reimbursable to the provider
This chart represents the percentage of calls that entered the queue and were answered.
The average time it takes for an agent to answer a call, reflected in seconds.
The average time callers are connected with agents.
The percentage of calls queued that are answered.
The average time it takes for an agent to answer a call waiting in the queue, reflected in seconds.
The average time callers are connected with agents.
This chart represents the percentage of calls that entered the queue and were answered.
The average time it takes for an agent to answer a call, reflected in seconds.
The average time callers are connected with agents.
The percentage of calls queued that are answered.
The average time it takes for an agent to answer a call waiting in the queue, reflected in seconds.
TERM DEFINITION
Average Speed of Answer A measure that reflects the average delay of all calls, including those that receive an immediate answer.
The average time callers are connected with agents.
This chart depicts the percentage of prescriptions reimbursed by Medicaid that were written for drugs on the Medicaid Preferred Drug List (PDL). The goal for this measure is to achieve adherence to the preferred list for 80% of Medicaid prescriptions. The list offers access to choices of prescription drugs within each therapeutic class. (Non-PDL products may be reimbursed with prior authorization.)
TERM DEFINITION
Preferred Drug List (PDL) A listing of prescription products determined to be efficacious, safe and cost effective choices when prescribing for Medicaid patients. The Medicaid Pharmaceutical and Therapeutics Committee reviews products and offers its recommendations for inclusion on the PDL.
Prior Authorization In order to be reimbursed by Medicaid, providers must obtain prior authorization before dispensing drugs that are not on the Preferred Drug List.
This chart depicts the collection percentage of dollars invoiced to pharmaceutical manufacturers for federal and state supplemental rebates for all drug claims reimbursed by Florida Medicaid.
Calculation based on Magellan rebates invoiced and total claim cost for the same quarter as Medicaid Program Analysis.
FY 2010-11 Appropriations vs Actual Spending, Fee for Service Pharmacy Program.
This chart reports the average retail price per prescription paid to Medicaid fee-for-service pharmacy providers prior to rebates, compared by month for 2010 & 2011.
This chart indicates the 8 most common reasons for why the State/Fiscal Agent returns a Medicaid Provider Enrollment Application. Providers, please ensure you or the person or entity filing your application includes these referenced and important documents.
This chart provides a count of the days involved with processing days, measuring from date of receipt to date the application is moved to the Quality Control (QC) review and/or returned to provider (RTP); the average count of days an application is in the RTP status, residing with the Fiscal Agent or the Provider/Applicant; and finally the count of days from resolution of outstanding items and QC effort to date of final determination, these 3 categories for counting days are respectively: Receipt to QC/RTP; Days in RTP Status; Days from RTP Status to Closure. The provider type groupings are:
This chart provides a count of the days involved with processing days, measuring from date of receipt to date the application is moved to the Quality Control (QC) review and/or returned to provider (RTP); the average count of days an application is in the RTP status, residing with the Fiscal Agent or the Provider/Applicant; and finally the count of days from resolution of outstanding items and QC effort to date of final determination ¿ these 3 categories for counting days are respectively: Receipt to QC/RTP; Days in RTP Status; Days from RTP Status to Closure. The provider type groupings are:
This chart provides a count of new applications approved/denied (processed by the fiscal agent), by month, categorized into 6 groups, (combinations of provider types of which there are a total of 63 types). This count takes into account applications that were received in previous months and now approved or denied. The groupings are:
This chart provides a count of new applications received, by month (divided in the count by applications submitted thru the web, and in paper), categorized into 6 groups (combinations of provider types of which there are a total of 63 types). The groupings are:
Monthly pageviews for http://ahca.myflorida.com
This chart shows the most popular pages visited on FloridaHealthFinder.gov for 2011.
This chart shows the number of visits, by year, to www.FloridaHealthFinder.gov. The consumer web site went live on November 8, 2007 - 63,908 visits.
This chart shows the number of visits, by month, to www.FloridaHealthFinder.gov. The consumer web site went live on November 8, 2007 - 63,908 visits.
This chart shows the most popular pages visited on FloridaHealthFinder.gov for 2011.
