Managed care monopoly?

ORLANDO, Fla. - Industry stakeholders are taking issue with Univita Health's role as both a third-party administrator (TPA) and HME provider in Florida's transition to managed care for Medicaid.

Univita has been chosen as the network administrator for 10 of the 14 plans participating in the program, representing roughly 84% of impacted Medicaid recipients. That means it decides which providers are allowed into its network and which get referrals, according to Deanna Rollyson, president of the Florida Alliance of Home Care Services (FAHCS).

“This can be problematic because, as both a TPA and a provider, it is directing referrals to itself and thus has the potential to eliminate competition among Florida's more than 4,000 independent DME providers and to eliminate choice to beneficiaries across the state,” she said.

Univita, which manages and coordinates care for health plans, became an HME provider when it acquired All-Med Services of Florida in 2012.

Even where Univita has gaps in coverage and, therefore, needs to subcontract, providers are concerned with the contracts they're being offered, Rollyson says.

“According to FAHCS members, Univita's current contracts offer only 50% of the current Florida Medicaid fee schedule as payment, which is unsustainable, and has required a non-compete agreement from every subcontractor,” she said.

Attempts to reach Univita were unsuccessful.

Stakeholders are in a race against the clock to make the program more equitable for HME providers and to ensure access for Medicaid recipients: Florida began the transition to managed care in May and expects to complete the process by October.

FAHCS has focused its efforts on requiring Florida Medicaid to enforce the state's any willing provider (AWP) provision through the legislative process, Rollyson says.

“A legal process may also be required,” she said. “The two are not mutually exclusive.”

The law firm Munsch Hardt, on behalf of “a couple of provider clients,” is also exploring the legality of the program, on the grounds that its current structure violates anti-trust laws and allows Univita to have a monopoly, says attorney Edward Vishnevetsky. In a white paper for Florida Medicaid, it recommends, among other things, that the state deny “approval of authorized exclusive provider organizations where there is common control or ownership between or among the managed care plans, TPAs and/or providers.”

Both Rollyson and Vishnevetsky warn that this issue is not a Florida issue. Other states are looking to managed care to reduce costs associated with Medicaid, opening the door to increased vertical integration—when different levels of health care are provided by the same company.

“The point isn't really Univita,” Vishnevetsky said. “It's this vertical integration model that's new in the anti-trust world. Typically, you see two providers merge together; this is a new model that could be a significant detriment to health care.”