Florida fines its largest Medicaid vendor more than $9 million

by | Mar 24, 2022


The state of Florida fined Sunshine State Health, its largest Medicaid payment vendor, $9.1 million in fines regarding software problems that delayed payments for 3 months for tens of thousands of healthcare claims.

The payment delays meant that critically ill Floridians who relied on Medicaid-paid health providers were unable to seek and adequately pay for treatments. In a letter to the CEO of Sunshine State Health, the Agency for Health Care Administration requested detailed explanations as to how the problems occurred and whether the company appropriately responded. The letter also required a demonstration within 30 days that future claims would be punctually paid.

The state’s health care regulator also revealed that the number of affected claims – 121,227 – was far higher than Sunshine State had previously acknowledged, as reported by the Orlando Sentinal.

Sunshine State Health previously claimed that the payment processing issues impacted just 0.5 percent of its 9.2 million total payment claims it processed during the period, or about 46,000 claims.

Sunshine State previously said the glitches originated from the company’s merger with the second-largest payment vendor, WellCare of Florida Inc. Combined, Sunshine and Wellcare have multi-year contracts worth $31.6 billion from the state’s Agency for Health Care Administration, according to figures from the state’s chief financial officer, according to Fresh Take Florida.

Florida lawmakers recently passed a bill in order to reform Medicaid managed care. The bill, SB 1950, along with its companion House bill, works to reform the Medicaid managed care system that has been in place since 2013.

The Senate’s bill places a cap on so-called “automatic enrollment” in Medicaid managed care plans, which is a program that automatically assigns families to a specific company’s plan if one isn’t already selected. The bill would prevent larger plans with more than 50 percent of regional market share from participating in the automatic enrollment program, allowing smaller providers to compete.

The bill also requires “essential providers,” like some hospitals, to sign contracts with existing Medicaid managed care plans in each region where they operate, or on a statewide basis.

1 Comment

  1. Dwayne Mann

    The Florida legislature just recently approved a plan to make significant changes to Medicaid managed care. SB 1950 and its companion bill in the House would try to alter the Medicaid managed care system that has been in place since 2013. This system has been in operation since 2013.

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