Florida Medicaid manages quality improvement contracts to ensure that Medicaid recipients receive medically necessary, quality services in the most cost effective manner.The following Medicaid services are subject to quality management review:
The organizations providing quality management review services currently under contract with the Agency are Magellan Medicaid Administration, The University of South Florida, Qlarant Quality Solutions, Centric Consulting, LLC, Healthy Start, KEPRO, and The University of Florida.
The Magellan Medicaid Administration provides Care Coordination Services for fee-for-service Florida Medicaid recipients receiving treatment within an in-state or out-of-state residential provider setting. Care coordination consists of treatment plan review, discharge planning and aftercare follow-up. The Vendor ensures that Florida Medicaid recipient children do not remain in long-term residential care if it is not medically necessary. The goal of the Program is to ensure that the recipient returns to their home community successfully.
The University of South Florida coordinates and maintains a Medicaid Drug Therapy Management Program in accordance with Section 409.912(8)(a)10, Florida Statues. The program is designed to improve quality of care and prescribing practices based on best practice guidelines, improve patient adherence to medication plans, reduce clinical risk, and lower prescribed drug costs, and the rate of inappropriate spending on Medicaid behavioral health drugs and certain related drugs.
Qlarant Quality Solutions is a federally designated Quality Improvement Organization (QIO) that provides quality assurance for Florida’s Developmental Disabilities Services system. Qlarant works in partnership with the Agency for Persons with Disabilities (APD) at the state and regional offices to improve the quality of supports for Medicaid recipients with developmental disabilities. The developmental services system, called iBudget Florida, gives APD Medicaid recipients more control and flexibility to choose services that are important to them. This program measures the success of services and supports from the blended perspectives of both the individual receiving services as well as program measures and requirements. The goal of this program is to assist the recipients living their everyday lives through quality improvement strategies designed to promote a person directed service delivery system.
Centric Consulting, LLC. operates an Electronic Visit Verification (EVV) Program of home health services provided through the Florida Medicaid fee-for-service delivery system in accordance with section 409.9132, Florida Statutes (F.S.). The Vendor’s EVV system (Smart Phone Mobile Application, Dashboard, and Claims Portal) verifies the utilization and delivery of home health services (home health visits, private duty nursing, and personal care services) using technology that is effective for identifying delivery of the service and deterring fraudulent or abusive billing for the service. The EVV Program provides an electronic billing interface and requires the electronic submission of claims for home health services.
Home Health Providers who do not wish to use the Vendor’s EVV system may use an EVV third-party integration option for approved integratable systems. Third-party integration means that a home health provider who has an EVV system may continue to use it to capture and send EVV data to the Vendor EVV claims system for billing.
Healthy Start MomCare Network, Inc., Section 409.906, Florida Statutes (F.S.). directs the Agency for Health Care Administration (Agency) to contract with an administrative services organization (ASO) representing all Healthy Start Coalitions, providing risk appropriate care coordination and other services in accordance with applicable statutes and federal waiver(s). The primary purpose of the Healthy Start Program is to increase the delivery of effective, evidence-based services that reduce infant mortality, reduce the number of low birth weight infants and improve health and developmental outcomes for Florida Medicaid enrollees.
KEPRO administers the Pre-Admission Screening and Resident Review (PASRR), a federally required review mandated by the Social Security Act, Title 42, Subpart C, Sections 483.100 through 483.138, Code of Federal Regulations. PASRR is intended to ensure that Medicaid-certified nursing facility applicants and residents with a diagnosis of, or suspicion of, serious mental illness of intellectual disabilities, or related conditions, are identified. A PASRR is required for all applicants to, and residents of, Medicaid-certified nursing facilities, regardless of payor.
The University of Florida coordinates and maintains the Regional Perinatal Intensive Care Centers (RPICC) Program, a comprehensive, statewide, high-risk neonatal/obstetrical health care delivery system. The RPICC program contains demographic and medical information on high-risk pregnant women and newborns that receive intensive care services in the eleven regional centers in Florida. The program is administered by the Department of Health (DOH), and Children’s Medical Services (CMS).