Denials and Cash Flow: Preparing for the CMS Plan Transition
Part of our guide to the CMS Plan transition. Jessie Solognier, COO of Edwards Electronic Processing (EEP), on what the last Florida CMS Plan handoff looked like from the billing side, and what to do about it financially.
What’s happening
Florida has changed CMS Plan owners before. When Sunshine Health took over the CMS Plan years ago, the handoff went through, but the first few weeks saw denials at a scale most clinics weren’t staffed for. That history is a useful guide available for the October 1 transition.
AHCA’s transition guidance says prior authorizations approved before October 1 are to be honored, which is a meaningful protection. Whether authorization records move cleanly between two different systems is a separate question. For the transition overview, see our guide to the CMS Plan move to Molina.
What we know
The commitment: Prior authorizations approved before October 1 are to be honored under AHCA’s continuity-of-care guidance.
The practical risk: Honoring an authorization and having it visible in the new plan’s system are not the same thing.
The likely window: In EEP’s experience with the prior transition, denial volume concentrated in roughly the first 30 days.
The exposure: CMS Plan children make up about half the patient base across EEP’s client practices.
The interview
Your team worked through the last CMS Plan transition. What was hardest?
Denials. Plans go into these transitions expecting the systems to carry everything across. Authorizations transfer, everything loads, and it’s fine. In practice, the systems are entirely different, and in our experience, roughly a quarter of the authorizations actually came across. So claims went out and came back denied for no authorization on file, or the patient not being found because a registration hadn’t landed. Then you’re filing appeals while payments slow down.
Erroneous claim issues and rejections are frequent in the first 30 days of a transition like this. Then the providers voice their concerns, and under pressure, the plan usually loosens requirements, like turning off claim edits for a short period of time. I’d expect a version of that pattern again, though every changeover has its own character.
AHCA says prior authorizations will be honored. Doesn’t that solve it?
It’s a meaningful protection, and I don’t want to minimize it. AHCA’s guidance says authorizations approved before October 1 are to be honored by the new plan. But honored and visible in the new system on day one are two different things. We experienced similar friction in the previous transition. The commitment might be held, but the data could not transfer.
So know which authorizations you hold going into October. Track the numbers, approval dates, and the units. Then a denial can be answered with a record rather than a search.
What should a clinic do when a claim comes back “no authorization on file”?
Answer it with documentation. If the authorization was approved before October 1, the guidance says it should be honored, so a denial like that is usually due to a systems gap rather than a coverage decision. Make sure any authorization approvals are scanned into the patient’s chart so they can be easily accessed for an appeal if needed.
The best way to resolve this can differ. Last time, some issues cleared with a call for reprocessing and others needed a formal appeal, and it took a few weeks of volume to learn which was better and most efficient. Track these as a group, not one claim at a time. A recurring trend, such as weekly denials for the same patient or all of one therapist’s claims being denied, usually means the fix lies on the plan’s side.
How does a billing team respond when that happens at scale?
We try to develop a single standard approach, rather than improvising on a claim-by-claim basis. We determine what’s actually resolving the issue (e.g., a call for reprocessing versus a formal appeal), then apply it to every client at once using common forms and instructions.
There’s also an advantage in seeing the whole book. We can tell whether a denial wave is hitting everyone or just one practice. If you’re billing in-house, that call is hard to make, and the not-knowing can be painful. You’re auditing your own work while the real cause sits on the plan’s side.
And if the same denial reason keeps repeating?
Escalate it as one issue, not many claims. Report the pattern to the plan with examples. Plans often adjust once a consistent problem is visible to them, which is roughly what we saw last time. If it persists after you’ve raised it, AHCA’s complaint process is a legitimate next step.
Where will clinics feel this most?
Cash flow. Our clients are used to CMS paying reliably. We bill, and the payment follows about a week later. Some of them write to us if a Monday payment is a day late. Now set that against roughly half the patient base, and add denials, appeals, and slower processing in the same window.
Planning ahead takes the edge off. Even a clinic that runs this changeover well is likely to see elevated denials and slower payments for a stretch. Build some slack before October, whatever that looks like for your practice. Many clinics run tight against payroll, and this is the moment to have a plan for a slow month rather than discover one.
Preparing financially
- Assume a slower October and November and plan cash for it.
- Know which authorizations are active going into October, so a denial can be answered with a record rather than a search.
- Watch denial patterns in the first 30 days and treat repeat reasons as a systemic issue to escalate, not a claim to rework.
- Report repeat denial reasons to the plan rather than absorbing them. Plans often adjust once a consistent problem is visible to them.
Where EEP fits
EEP focuses on speech therapy, physical therapy, occupational therapy, and ABA therapy. We worked on the last CMS Plan transition, and running one appeals playbook across many practices means a fix found on Monday can be in place everywhere by Tuesday, rather than being rediscovered clinic by clinic. If you’d like to speak with someone at EEP about outsourcing your billing, you can reach us here.
Continue the guide
The CMS Plan moves to Molina: what changes and how much volume is exposed.
Credentialing with Molina: the step with a deadline attached.
What changes inside the claim: routing, remittances, and plan updates.
Resources
Molina provider services: (855) 322-4076 / CMS Plan inquiries: CMSplan@molinahealthcare.com
AHCA Medicaid complaints: 1-877-254-1055
General information reflecting EEP’s experience as of August 2026, not legal, coding, or reimbursement advice. Transition details are still developing and vary by plan. Verify current requirements with Molina and AHCA before you act.
