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Office of Program Policy Analysis and Government Accountability

Medicaid Program Integrity Recovers Overpayments in Fee-For-Service and Monitors Fraud and Abuse in Managed Care, Report No. 14-05, January 2014
 
Full report in PDF format


  • As of November 2013, 53% of Florida’s Medicaid population was served by fee-for-service providers and 47% by managed care plans. As directed by law, the Agency for Health Care Administration (AHCA) is continuing to expand managed care statewide and expects that 85% of beneficiaries will be enrolled in managed care plans by October 2014.
  • For fee-for-service providers, AHCA has reduced the time it takes to recover overpayments and increased the fines and penalties imposed for provider overbilling. The agency also is procuring an advanced detection system and a case management system that will enhance fraud and abuse efforts for both fee-for-service and managed care plans.
  • To reflect the shift to managed care, AHCA is revising its organizational structure. It also requires managed care plans to establish program integrity functions and activities to reduce the incidence of fraud and abuse. In addition, AHCA is developing accountability systems that will enhance its ability to monitor managed care and identify program integrity concerns.

Which Government Program Summaries contain related information?

Agency for Health Care Administration
Medicaid Health Care Services

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. 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, November 2004,published in November 2004.
  • Report No. 01-39 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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