Buying a home care agency in South Florida

• Referrals from many hospitals, doctors' offices, senior communities and case managers, not one or two relationships the owner holds personally.
• A core group of caregivers who have stayed for years, and steady hiring that keeps shifts filled without constant overtime.
• A director of nursing and an office team who run intake, scheduling and billing without the owner.
• For Medicare-certified agencies, clean recent surveys (inspections) and solid ratings on Medicare's Care Compare website.
• For private-pay agencies, long client relationships and a mix of payers, so no single Medicaid plan or insurer controls the business.
• Files that would survive an audit: background screening, training records, visit notes and physician orders, all current.
• Scheduling and visit verification that run smoothly. Florida's Medicaid plans require electronic verification of home health and personal care visits.

• Payers. Medicare rates change yearly, Medicare Advantage plans often pay less and require approvals, and Medicaid plan contracts can end. Florida is part of Medicare's Review Choice Demonstration, which reviews traditional Medicare home health claims before or after payment. Ask for the agency's results.
• Audit history. Records requests, denied claims and repayment demands. The seller stays liable for AHCA penalties from before the sale (section 408.807), but Florida Medicaid can also hold the buyer liable for overpayments identified by closing (section 409.907(6)). Ask AHCA, and cover the rest in the contract.
• How caregivers are paid. Treating aides as contractors outside a licensed nurse registry, or skipping overtime, can leave the business owing back wages. Federal overtime rules for agency caregivers are being revisited, so have an employment attorney look.
• The service area. A home health agency license lists the counties it may serve, all in one state health planning district. Adding counties takes an AHCA filing, and going beyond the district takes a separate license (rule 59A-8.003).
• People. Caregiver turnover, pay compared with local competitors, and any liability claims involving falls or missing property.

• Where do most new patients or clients come from, and which referral sources know you personally?
• Who pays for most of your clients' care, and has any payer changed rates or terms lately?
• How long do your caregivers usually stay, and how do you find new ones?
• When were your last AHCA survey and accreditation visit, and what came up?
• How have your claims fared under Medicare's Review Choice Demonstration? Any audits or repayment requests?
• Who handles intake, scheduling and nursing oversight day to day, and do you think they'll stay?
• Do you turn away any areas or kinds of clients because you can't staff them?

South Florida covers Miami-Dade, Broward, Palm Beach and Monroe counties: Miami, Hialeah, Doral, Fort Lauderdale, Hollywood, Pompano Beach, West Palm Beach, Boca Raton, Jupiter, and the Florida Keys down to Key West. It's the state's largest metro area and its most international. PortMiami, Port Everglades and Miami International Airport tie the region to Latin America and the Caribbean, which supports a deep base of wholesalers, freight forwarders and logistics firms, many of them near the airport. Tourism and cruises, finance and wealth management, health care, real estate and construction carry much of the rest. Palm Beach County adds wealthy seasonal residents and, out west near Lake Okeechobee, sugarcane and vegetable farms. In the Keys, nearly everything turns on visitors, fishing and boating.

Companies that serve homes, condo buildings and other businesses do well here: the building trades, property services, insurance agencies, medical and dental practices, and professional firms.

Costs run high: commercial rent, wages and, above all, property and windstorm insurance. Price the insurance before you make an offer, not after. Miami-Dade and Broward make up the Florida Building Code's High-Velocity Hurricane Zone, with stricter rules for roofs, windows and structures. That raises building costs, and it also gives steady work to the contractors who know those rules well.

Much of the workforce and many customers speak Spanish as well as English, and a company that works well in both languages has an edge. The winter season matters more in Palm Beach County and the Keys than in Miami. In the Keys, the cost of housing makes hiring and keeping staff one of the hardest parts of running a company. Ask any seller there how they find workers and where those workers live.