The Music Therapy Crisis in Florida and What It's Teaching Us

Music therapists in Florida are in an escalating crisis. As I write this, a large share of private practitioners - both business owners and the therapists working under them - are going unpaid by one of the key payers of services in the state. Over the last several months, payment schedules were extended, creating large sums of accrued claims owed for reimbursement. Then, in recent weeks, payments came to a sudden and unanticipated halt. So, what the heck is going on?

The truth is: No one knows. But there is a ton of speculation circulating throughout the music therapy community. Some suspect financial insolvency and potential bankruptcy. Others believe the reason is due to insufficient cash flows. A colleague pointed out how these issues happen to coincide with the impending decision on the One Big Beautiful Bill Act (H.R. 1), and its significant implications for Medicaid.

I’m not going to add to any of this speculation. Instead, I prefer to explore what we can learn from the experience and do to better sustain our meaningful profession.

The Arrangement

In Florida, music therapy essentially has a single pathway for insurance reimbursement, but it’s a bit more complicated than some believe. Music therapists, art therapists, pet therapists, and equine therapists contract with a company called Medical Transportation Management (MTM) to get paid for their services. To be eligible for reimbursement, those providers render services per the requirements outlined by MTM (45 minutes of therapy by a credentialed provider) and submit claims through an Expressive Therapies portal, housed by MTM. Clients, or “members,” are assigned to providers in the portal. Then, the providers see them and submit claims in accordance with their agreement. MTM pays the providers a flat rate by session type (individual or group). That structure is known as fee-for-service (FFS). Pretty simple, right?

So, where does MTM get the money?

This is where it gets complex. MTM is what’s called a fiscal intermediary, an organization that manages the financial and administrative functions of a program on behalf of another party. They’re common in healthcare and other government-funded programs. The fiscal intermediary, MTM in this case, serves as a middleman between the party delivering services (music therapists) and the payer. 

In Florida, this payer is ultimately Medicaid. But Medicaid doesn’t actually pay for music therapy specifically, nor do they pay MTM directly. They partner with other companies called managed care organizations (MCOs) to administer funds and services. Those MCOs receive what’s called a capitated (or "per head") payment for each member on a recurring basis.

Most of these arrangements are on a per-member-per-month (PMPM) schedule. It looks like this:

1. State and federal tax dollars go to fund Medicaid.

2. Medicaid pays the MCO (e.g., Sunshine Health, a subsidiary of Centene Corporation) a PMPM payment.

3. The MCO pays MTM, a subcontractor, for specific services like medical transportation and therapies (commonly on a PMPM basis, though it can vary by agreement).

4. MTM then subcontracts providers and pays them on a fee-for-service agreement.

Fiscal intermediaries exist to help better coordinate care for improved outcomes and efficient fiscal management. And as you can likely conclude by the payment process from start (beneficiaries) to end (providers), their profit comes from the savings in how well they manage the funds from MCOs. In Florida, the dollars paid for music therapy are made available through Medicaid under the Home and Community-Based Services (HCBS) waiver, a program that provides funds to help provide services like therapy to individuals in their homes and outpatient settings, since these are more cost-effective than inpatient alternatives. 

So, in this case, the fiscal intermediary (MTM) gets funds from the MCO (Sunshine Health or Children’s Medical Services), and manages them to administer services to its members in homes or outpatient settings. It pays subcontractors like music therapists to manage the members’ clinical needs, and it gets to retain the savings. 

This is an increasingly common structure since the Patient Protection and Affordable Care Act. It’s intended to incentivize quality and efficiency of care over quantity of services provided.

Finally - and this is big for music therapists to understand: Music therapy is not a core Medicaid benefit. MCOs aren’t required to cover it - some choose to as an optional service under Florida’s HCBS waiver. Since MCOs like Sunshine Health and Children’s Medical Services have elected to offer music therapy as an expanded benefit, and they delegate the administrative oversight of expressive therapies to MTM, MTM has the ability to set the terms under which that care is delivered. The MCOs, however, still maintain the authority to revise or override those terms, especially when member outcomes or the viability of the program are at stake. 

Operational or financial issues with any agent in this payment process would trickle down to providers.

This is where the discussions around licensure get interesting. Stay tuned for another article on that in the future.

The Problem

Since first contracting with music therapists in Florida back in 2019, the arrangement with MTM operated pretty smoothly. Providers did their sessions, billed MTM, and were paid with a quick-turnaround. The system was working so well that the state saw a steady increase in providers going into private practice, perhaps in spite of (or even attributed to) Covid-19. 

By April of 2025, there were 97 credentialed music therapy vendors in MTM’s Florida network, many of whom had multiple therapists under their contracts.

It’s important to note, however, that not all of these vendors provide “music therapy” in the technical sense. Music therapy does not require licensure in Florida, so use of terms like “music therapy” and ”music therapist” aren’t legally protected like they might be in other states. Additionally, MTM does not require board-certification to be credentialed in their network - only a bachelor’s degree in music (no, not even in music therapy) - to meet requirements for eligibility. And while that is an entirely separate issue, many believe it contributed to the problems today.

The point is: Music therapy is booming in Florida. And it’s a great thing. Patients have access to care and providers have access to funding. So what’s the problem?

As one might expect, most practices leaned heavily into this MTM arrangement. I believe most business owners would agree with me when I say, “The problem with being a music therapist isn’t getting people to want services - it’s finding ways to pay for it.”

And the waiver fixed that very problem. Under this arrangement, families are receiving music therapy with no out-of-pocket costs, and music therapists are finally able to obtain viable rates for their valuable work. 

As practices grew in size and quantity, MTM actually closed its provider portal, meaning that they were no longer accepting new vendors for these services (they have since opened it for select, underserved regions of the state). And while this concerned some as to why, it’s quite common in healthcare. For example, both hospitals and hospices require a certificate of need (CON) in Florida to enter the market. 

Then, in the fall of 2024, music therapists started to worry. After years of relatively seamless operations, MTM updated its payment schedule from about a 2-day turnaround to a net 30 arrangement. This meant that, instead of receiving reimbursement each Friday from the close of the last billing cycle (ending every Wednesday at 5pm CST), providers would be paid within 30 days of submitting claims.

It should be noted that this, in itself, is not a cause for concern. Net 30 payment schedules are actually quite common in healthcare, and for many settings - pretty quick. And as a provider in this plan, I was actually impressed with how the announcement was rolled out. Providers received several weeks’ notice, and the adjustment was made in increments to allow providers time to make adjustments for disruptions to cash flow.

And here’s where it hits the fan.

A net 30 payment schedule means that all providers perpetually have a month’s worth of claims accrued. And, assuming they’re paid weekly, that balance should remain relatively stable. 

But what providers started to see was that, while they were still making money, they didn’t necessarily have it. This is a common issue in any business, but specifically in healthcare, with third-party reimbursement structures. But when you’re getting paid a month after providing services, especially when your expenses haven’t changed with the inflow of cash, it’s critical that you’re paid on time. And that’s where things have gone wrong.

For the last two weeks, MTM providers haven’t received payments for their claims. And this is compounded by the fact that they also have an additional month’s worth of cash hanging in unpaid accruals. 

To make matters more concerning, in the midst of the non-payments (vaguely explained as “accounting issues” by the MTM team), MTM notified all providers of an immediate change, capping sessions to no more than once per week for all members, regardless of previously approved authorizations and visit frequencies.

The context of this sudden and unanticipated change, made during the ongoing ambiguity of why providers haven’t been paid, and heightened by the large (and growing) sums of money owed to providers across the state has everyone asking: Will I ever get paid? What does this mean? And what do I do now? 

The Lessons

As I mentioned, there is a lot being said in our community right now, and much of it is speculation. I don’t know, nor am I pretending to know the reasons for why providers aren’t being paid. I have no comment on the decisions by Sunshine Health's or MTM’s leaders to best manage their companies other than, “Thank you for the opportunity to serve these members.”

We may not understand what’s happening with MTM, but here are some of the lessons we’re learning in real time, whether we want to or not…

Cash is King

“A bird in the hand is worth two in the bush.” That’s the exact lesson most private practice owners in Florida are thinking about right now.

When you’re running a business, there’s a lot more to consider than just if you’re making money. It also matters when you make it. This is why the question of if providers get paid by MTM is only part of the problem now: If it isn’t soon, many of them won’t have enough to stay afloat.

You can’t pay your bills on accruals or outstanding revenue. You can’t clear payroll on what clients owe you - not until you have it. You have to properly manage cash flow.

This goes hand-in-hand with enriching your payer mix (see below), since having multiple streams of revenue can help to stagger payments when you’re having issues getting paid from one of your clients or funding sources. Additionally, should any of your clients or partners change payment terms (e.g., move from net 30 to net 45 or net 60) or terminate your relationship, having cash on hand is crucial for making ends meet for the interim.

The Reality of Key Client (or Payer) Risk

There’s a reason financial planners talk about the importance of diversifying investments, and it ultimately comes down to managing risk. That’s an important word, by the way - managing - not eliminating. You buckle your seat belt, but you can still get in a car accident. You wear a mask, but you still contract a virus. You research before buying a stock, but the value still tanks.

The truth is: We can’t eliminate risk; we can only do our best to minimize it. 

One of the ways we can minimize our risk as business owners is to diversify our payer mix. In private practice, this means seeking out clients with multiple fundings sources - different insurance waivers, self pay, scholarships, grants, and facility partnerships. It’s an important way to strengthen the financial health of our businesses. It also makes them more attractive to potential buyers. But the implications for this go beyond private practice alone. 

I used to serve as a hospice music therapist. The program was funded entirely by the charitable donation of a single family. One day, after working for the company for a while, I sat down with them and a member from our foundation for lunch. At the end of our meeting, I literally watched them hand the foundation director a single check to fund my salary and all the program’s costs for a three-year period. That isn’t a strong position for any program, and the reality is, it’s the exact situation many music therapists working in hospitals, hospices, or non-profits are in (if you don’t believe me, think back to the panic during the early days of DOGE). 

The Vulnerability of The Field

The reality is that many of our colleagues’ programs or businesses are one key grant, one key donation, one key client, or one key payer from becoming non-existent.

That isn’t to say there aren’t healthy programs, or even private practices, out there. There are. They're the ones who have diversified their payer mixes and revenue streams. They’ve built up cash reserves. They’ve partnered with large organizations with access to resources. Ultimately, they’ve done much more than tap into a path to reimbursement and put all their eggs in one basket - they’ve grown, adapted, withstood the test of time, and proven their value. Unfortunately, those programs are few and far between.

When you’re in a situation where you’re dependent upon a single entity, donor, grant, or payer to pay you on-time, every time, in full, as agreed, without fail, and in perpetuity, you’re destined for trouble. 

For the sustainability of our profession, it is imperative that we create more opportunities for funding services. This means forging partnerships with insurance companies to bill for services directly, obtaining music therapy-specific CPT codes, advocating for - not just licensure - but also the expansion of programs like Medicaid to cover music therapy explicitly (not just as an expanded benefit), pushing for viable reimbursement rates, and developing the research to evidence how our services impact what motivates decision-makers most: costs and revenue.

And no one is coming to do this for us. It’s our responsibility.

The Cost

This is business, folks. As a business owner, I accepted the risks of going out on my own (shoutout to my partner, Karen) to build something that I thought was worth more than what it would cost me. 

And if you’re a music therapy business owner in Florida, you’re probably looking at those costs right now, too. You’re probably weighing some options right now - heavily. Some practices are implementing a pause on all MTM-funded clients. Some are moving away from MTM altogether. Since the portal has been closed for many, we’ve seen practices launch with no funding from MTM whatsoever. It’s a trying time for all of us, to say the least.

But this is how business innovates. The greatest opportunities often flow from the most seemingly insurmountable challenges.

Again, I don’t know what is happening with MTM, Sunshine Health, or even Medicaid right now - nor am I pretending to. I believe it’s perfectly reasonable to assume they are doing what’s best for their members and their organization, and that this matter will be resolved any day. That is my hope. To every provider out there worrying, struggling, fighting for the livelihood of your business and your team, my heart goes out to you.

And if you’re employed by a music therapy business owner, or considering going into practice for yourself, pay attention. This is a fantastic opportunity to learn one of the biggest lessons in entrepreneurship, and you’re watching it unveil itself in real-time. And what is that, exactly? 

The cost of doing business.