The Florida Legislature
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Office of Program Policy Analysis and Government Accountability

Medicaid Program Integrity Efforts Recover Minimal Dollars, Sanctions Rarely Imposed, Stronger Accountability Needed, Report No. 01-39, September 2001
 
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The Agency for Health Care Administration is responsible for administering Florida’s Medicaid program. To receive federal Medicaid funds, the agency is required to develop methods and criteria for identifying and investigating Medicaid providers suspected of abuse and procedures for referring cases of suspected fraud to the state’s Medicaid Fraud Control Unit, located in the Department of Legal Affairs. The agency’s Office of Program Integrity is responsible for these functions.

During the six-year period, from Fiscal Year 1995‑96 to Fiscal Year 2000-01, the agency recovered $96.7 million from providers that over billed the Medicaid program. During this same period of time, estimates of Florida’s losses due to Medicaid fraud and abuse range from $2.1 billion to $4.3 billion, or between 5% and 10% of total Medicaid health services expenditures. By recovering $96.7 million, the agency in effect recovered only from 2.3% to 4.5% of the money likely lost to fraud and abuse during that time period.

Overall, the agency needs to improve its efforts to detect and deter Medicaid provider fraud and abuse and its methods of assessing the effectiveness of program integrity functions. To assist the agency in accomplishing these goals, we recommend the Legislature direct the Agency for Health Care Administration to

  • develop measures and standards for evaluating the success of program integrity efforts;
  • report to the Legislature on the extent to which the agency is meeting Program Integrity performance goals;
  • determine the extent of Medicaid fraud and abuse;
  • impose fines and other appropriate sanctions on providers that exhibit egregious behavior; and
  • develop and use detection and estimation methods that maximize the likelihood of identifying and recovering Medicaid funds lost to fraud and abuse.

Which Government Program Summaries contain related information?

Medicaid Health Care Services
Agency for Health Care Administration

What other OPPAGA-related materials are available?

  • Report No. 16-03 AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments,published in January 2016.
  • Report No. 14-05 Medicaid Program Integrity Recovers Overpayments in Fee-For-Service and Monitors Fraud and Abuse in Managed Care,published in January 2014.
  • Report No. 11-22 Agency for Health Care Administration Continues Efforts to Control Medicaid Fraud and Abuse,published in December 2011.
  • Report No. 10-32 Enhanced Detection, Stronger Sanctions, Managed Care Fiscal Safeguards, and a Fraud and Abuse Strategic Plan Are Needed to Further Protect Medicaid Funds,published in March 2010.
  • Report No. 08-08 AHCA Making Progress But Stronger Detection, Sanctions, and Managed Care Oversight Needed, published in February 2008.
  • Report No. 06-23 Enhanced Detection and Stronger Use of Sanctions Could Improve AHCA’s Ability to Detect and Deter Overpayments to Providers, published in March 2006.
  • Report No. 04-77 Progress Report: AHCA Takes Steps to Improve Medicaid Program Integrity, But Further Actions Are Needed, published in November 2004.
  • Report No. 01-61 Justification Review: Expected Medicaid Savings Unrealized; Performance, Cost Information Not Timely for Legislative Purposes, published in November 2001.
  • Report No. 01-27 Justification Review: Medicaid Disease Management Initiative Sluggish, Cost Savings Not Determined, Design Changes Needed, published in May 2001.
  • Report No. 01-24 Justification Review: Health Care Regulation Program Agency for Health Care Administration, published in May 2001.
  • Report No. 01-10 Justification Review: Growth in Medicaid Prescription Drug Costs Indicates Additional Prudent Purchasing Practices Are Needed, published in February 2001.
  • Report No. 97-11 Follow-up Report on Medicaid Managed Care Options, published in October 1997.
  • Report No. 96-14 Follow-up Report on Efforts to Identify and Deter Provider Fraud and Abuse in Florida's Medicaid Program, published in November 1996.
  • Report No. 94-47 Follow-up Review of Medicaid Managed Care, published in April 1995.
  • Report No. 94-18 Performance Review of Medicaid Managed Care Options, published in December 1994.
  • Report No. 12287 Performance Audit of Efforts to Identify and Deter Provider Fraud and Abuse in Florida's Medicaid Program, published in April 1994.

Copies of this report in print or alternate accessible format may be obtained by telephone (850/488-0021), by FAX (850/487-9213), in person, or by mail (OPPAGA Report Production, Claude Pepper Building, Room 312, 111 W. Madison St., Tallahassee, FL 32399-1475).
e-mail address: oppaga@oppaga.fl.gov


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