Exclusive Provider Organizations (EPOs) are individual providers or groups of providers who have entered into written agreements with an insurer to provide health care services to subscribers.
An insurer may not issue a policy or certificate that is subject to an exclusive provider provision until the EPO's plan of operation has been approved by the Agency. An EPO is required to maintain an internal and external quality assurance program and a subscriber grievance procedure for hearing complaints and resolving grievances.
PLAN OF OPERATION APPROVAL PROCESS:
Initial Application and Survey: Florida statute requires applications for approval of an EPO plan of operation to include:
- A listing of all providers, by specialty, contracted in the organization,
- Documentation describing specific provider responsibilities,
- Availability of 24-hour, 7 day-a-week emergency care services,
- Detailed description of the grievance procedure,
- Detailed description of the quality assurance program,
- Any limitations or restrictions on providers.
Monitoring: Monitoring of EPOs includes submission of provider networks every 6 months, annual grievance reporting, and investigations of quality of care complaints received.
Expansions: : An EPO may expand their geographic service area by submitting an expansion affidavit and supporting documentation requested by the Agency. When the affidavit and supporting documentation is reviewed and deemed complete, a letter of approval will be submitted to the organization. The affidavit also affirms consistent compliance throughout the expanded network with Florida statute and rule.