The Florida Legislature
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Office of Program Policy Analysis and Government Accountability

Performance Audit of Efforts to Identify and Deter Provider Fraud and Abuse in Florida's Medicaid Program Administered by the Agency for Health Care Administration , Report No. 12287, April 1994
 


  • The Agency for Health Care Administration (AHCA) administratively sanctions only a small number of providers who abuse Medicaid. During the last four fiscal years, the proportion of providers identified as having over-billed Medicaid who were sanctioned by the Agency ranged from 1.2% to 5.6%. The low number of sanctions imposed may be partly due to problems with staff adherence to the sanctioning process.
  • When staff did not document their use of violation and sanction matrices, they tended not to recommend sanctioning providers who over-billed Medicaid. Additionally, case files that did not contain matrices often did not contain all the information needed to determine the appropriateness of staff decisions not to recommend sanctions. Even when staff completed violation and sanction matrices, they often did not recommend the sanctions prescribed by rule. Staff reluctance to recommend prescribed sanctions may stem from their concerns that the sanctions will limit client access to Medicaid services.
  • The AHCA has not taken the steps necessary to ensure that providers who have abused Medicaid will discontinue the practices that led to the identified abuse. While the Agency seeks the recovery of overpayments and may sanction some providers, it does not have procedures that require Office of Medicaid Program Integrity staff to identify and monitor providers who have abused Medicaid. If the Agency does not purposefully monitor the billings of providers who have abused Medicaid, some of these providers may continue their abusive practices without being identified.

What were our earlier findings?

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.

Which Government Program Summaries contain related information?

Medicaid Program Integrity (Fraud and Abuse)

What other OPPAGA-related materials are available?

  • Report No. 01-61 Justification Review: Expected Medicaid Savings Unrealized; Performance, Cost Information Not Timely for Legislative Purposes, published in November 2001.
  • Report No. 01-39 Justification Review: Medicaid Program Integrity Efforts Recover Minimal Dollars, Sanctions Rarely Imposed, Stronger Accountability Needed, published in September 2001.

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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