Office of Program Policy Analysis and Government Accountability
Office of Program Policy Analysis and Government Accountability

Medicaid Program Integrity Efforts Recover Minimal Dollars, Sanctions Rarely Imposed, Stronger Accountability Needed

Report 01-39, September 2001




Report Summary

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.


Related Reports
  1. AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments
    Report 16-03 January 2016
  2. Medicaid Program Integrity Recovers Overpayments in Fee-For-Service and Monitors Fraud and Abuse in Managed Care
    Report 14-05 January 2014
  3. Agency for Health Care Administration Continues Efforts to Control Medicaid Fraud and Abuse
    Report 11-22 December 2011
  4. Enhanced Detection, Stronger Sanctions, Managed Care Fiscal Safeguards, and a Fraud and Abuse Strategic Plan Are Needed to Further Protect Medicaid Funds
    Report 10-32 March 2010
Copies of this report in print or alternate accessible format may be obtained by email OPPAGA@oppaga.fl.gov, telephone (850) 488-0021, or mail 111 W. Madison St., Room 312 Tallahassee, FL 32399-1475.
Copies of this report in print or alternate accessible format may be obtained by email OPPAGA@oppaga.fl.gov, telephone (850) 488-0021, or mail 111 W. Madison St., Room 312 Tallahassee, FL 32399-1475.
social services, health, medicaid, fraud and abuse, fraud, provider fraud, abuse