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