RFI 008-2324 Enhanced Provider Network.pdf

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

REQUEST FOR INFORMATION

Enhanced Provider Network Auditing Program

RFI RELEASE DATE: October 2, 2023

AHCA RFI 008-23/24, Page 1 of 5

TABLE OF CONTENTS

I. GENERAL INFORMATION

II. RFI RESPONSE INSTRUCTIONS

III. PUBLIC RECORDS EXEMPTIONS, TRADE SECRET OR PROPRIETARY

INFORMATION

IV. RESPONSE SUBMISSION

V. COSTS

VI. QUESTIONS

VII. AGENCY FOR HEALTH CARE ADMINISTRATION WEBSITE

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AHCA RFI 008-23/24, Page 2 of 5

I. GENERAL INFORMATION

A. Request for Information Process This is a Request for Information (RFI) as defined in Section 287.012(22), Florida Statutes (F.S.), for planning purposes. This RFI is issued by the State of Florida, Agency for Health Care Administration (Agency), to solicit information regarding available providers for the services described herein.

An RFI is not a method of procurement. Responses to an RFI are not offers and shall not be accepted by the Agency to form a binding Contract. This RFI and Responses to it shall not result in the execution of a contract with the Agency. By submitting a Response to this RFI, a Vendor is not prohibited from responding to any related subsequent solicitation. This RFI may be used for purposes of determining whether or not to competitively procure a commodity or contractual service, determining what solicitation process to use, or researching general, special, and/or technical specifications for a solicitation. The Agency reserves the right to utilize the information gathered through the RFI process to develop a scope of services, which may be incorporated into a contract using a statutorily approved method of procurement.

B. Background

In its Statewide Medicaid Managed Care (SMMC) program, the Agency contracts with a variety of managed care plans that include Managed Medical Assistance (MMA), Long-Term Care (LTC) and Dental plans. In each of these contracts, provider network adequacy standards are included, and the Agency currently monitors these standards in-house. Some of these standards include geographic access metrics (also known as time and distance), ratio metrics, accepting new Medicaid enrollee metrics, after hours/weekend access metrics, and appointment availability metrics. Methods used to monitor these standards include automated reports, self-reported data, online directory reviews, and secret shopper activities.

Plans are also required to submit a refresh of their full provider network file to the Agency weekly.

C. Purpose The Agency is seeking information from entities with experience in conducting network adequacy reviews for the purpose of auditing provider networks, including, but not limited to, conducting secret shopper activities and other activities to verify provider networks as identified by the Agency. The vendor will conduct systematic and continuous testing of the provider network databases maintained by the Managed Care Plans to confirm accuracy, confirm that providers are accepting enrollees, and confirm that enrollees have access to services, and provide the Agency with analytics, dashboards, and other reports as determined by the Agency. Payments shall include compensation of the vendor and necessary administrative costs of the Agency directly related to the audit activities.

Due to the size and complexity of these provider networks, including the timeframe for refreshing network data, the Agency is interested in innovative ideas and best https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care/2018-2024-smmc-plans

AHCA RFI 008-23/24, Page 3 of 5 practices on how to continuously review and validate provider network adequacy for Medicaid managed care plans.

Areas where the Agency requests ideas and methods for testing network adequacy include:

• Identifying true appointment wait times for a variety of provider specialties.

• Identifying true access availability to behavioral health inpatient and outpatient services.

• Identifying barriers in accessing timely appointments.

• Validating plans’ online provider directories and comparing against the plans’ submitted network files which would include, but not be limited to correct address/phone number where the provider is actually rendering services, and whether the provider is accepting new Medicaid enrollees.

• Validating Primary Care Providers (PCP) that offer after hours appointment availability to Medicaid enrollees.

• Identifying providers that are telehealth only.

• Validating specialty care utilization of non-participating providers meets the network standards, however, also confirming that plans are utilizing out-of-network providers and specialists as needed.

• Confirmation and analysis of network providers’ utilization, e.g., determining percentage of providers rendering services versus providers listed only to meet network adequacy requirements.

• Validating network waiver requests submitted by plans and confirming the lack of specific available providers.

• Monitoring and follow up on identified network deficiencies to ensure appropriate remediation.

• Recommending a monthly sample size for validating a managed care plan’s provider network.

For LTC services, the Agency is interested in confirming the availability of direct service workers (DSW) such as personal care workers, home health aides and homemaker services. Since these DSWs generally work for an agency and the managed care plans report their LTC provider network only at the agency level, it is more difficult to monitor and evaluate access in this area. In addition, these services are provided in-home rather than the enrollee going out to an appointment, therefore, it is also more difficult to monitor “appointment wait times”.

The Agency is interested in obtaining innovative ideas on how access to these services can be calculated and audited, from the actual number of DSWs (i.e., is the number adequate for the number of individuals needing services) to average amount of time from service authorization to receipt of services.

For Dental plans, in addition to the general network adequacy validations, the Agency is also interested in information regarding innovative methods or best practices in validating network providers identified as:

• Rendering services to special needs children and adults

AHCA RFI 008-23/24, Page 4 of 5

• Maintaining and utilizing listed sedation permits

• Accessing and utilizing Ambulatory Services Centers as needed

• Accessing and utilizing outpatient hospital services for non-emergency dental services as needed

II. RFI RESPONSE INSTRUCTIONS

Respondents to this RFI are asked to be thorough, but concise. The RFI Response should include the following:

A. The Respondent’s name; place of business address(es); Web Site address, if applicable; and contact information, including representative name and alternate, with telephone number(s) and e-mail address(es).

B. A statement of interest in the services outlined in this RFI, including an outline of a specific product, concept, technology, or approach that would meet the goals and requirements described in this RFI.

C. A description of the Respondent’s business and its experience as it relates to the services outlined in this RFI.

D. A description of how the Respondent’s approach will offer advantages or improvements. The description should also identify known or potential concerns with the approach.

E. A description of innovative approaches or best practices for validating and analyzing managed care provider networks against contract standards as described above and presented in various formats.

III. PUBLIC RECORDS EXEMPTIONS, TRADE SECRET OR PROPRIETARY

INFORMATION

Any portion of the submitted Response which is asserted to be exempt from disclosure under Chapter 119, Florida Statutes, shall be clearly marked “exempt”, “confidential”, or “trade secret” (as applicable) and shall also contain the statutory basis for such claim on every page. Pages containing trade secret shall be marked “trade secret as defined in Section 812.081, Florida Statutes”. Failure to segregate and identify such portions shall constitute a waiver of any claimed exemption and the Agency will provide such records in response to public records requests without notifying the Respondent. Designating material simply as “proprietary” will not necessarily protect it from disclosure under Chapter 119, F.S. An entire Response should not be considered trade secret.

Respondents who fail to identify trade secret as directed herein acknowledge and agree that they waive any right or cause of action, civil or criminal, against the Agency for Health Care Administration, its employees and its representatives, for the release or disclosure of trade secret information not so identified.

AHCA RFI 008-23/24, Page 5 of 5

IV. RESPONSE SUBMISSION

Respondents to this RFI shall submit one (1) electronic copy of its Response. The Response shall not exceed forty (40) pages in length. The electronic format shall be submitted via e-mail. The software used to produce the electronic files must be Microsoft Word 2013 and/or Excel 2013 or newer. The electronic files must be logically named.

The Respondent shall also submit via e-mail one (1) electronic redacted copy of the Response suitable for release to the public. Any confidential or trade secret information covered under Section 812.081, Florida Statutes, should be either redacted or completely removed. The redacted Response shall be marked as the “redacted” copy and contain a transmittal letter authorizing release of the redacted version of the Response in the event the Agency receives a public records request.

Responses to this RFI shall be provided no later than 2:00 PM, Eastern Standard Time (EST), November 13, 2023. Responses shall be e-mailed to Solicitation.Questions@ahca.myflorida.com.

Responses shall be addressed to:

Weston McKain Procurement Officer Solicitation.Questions@ahca.myflorida.com

After the Agency has received all Responses to this RFI, the Agency, in its sole discretion, shall determine if a meeting with Respondent(s) is necessary to clarify the information received. In the event that the Agency decides to hold a meeting, the Respondent(s) will be notified via email.

V. COSTS

Respondents are responsible for all costs associated with preparing a Response to this RFI. The State of Florida, Agency for Health Care Administration, will not be responsible for any Respondent costs associated with preparing a Response to this RFI.

VI. QUESTIONS

Questions concerning this RFI shall be submitted in writing via email to Solicitation.Questions@ahca.myflorida.com no later than 2:00 PM, EST, October 16, 2023. The Agency will reply to all questions by 5:00 PM EST, October 30, 2023.

Agency responses to written questions received will be made publicly available in the Vendor Information Portal.

VII. AGENCY FOR HEALTH CARE ADMINISTRATION WEBSITE

Additional information about the Florida Agency for Health Care Administration can be found on the Agency’s website at: https://ahca.myflorida.com/

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