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Office of Program Policy Analysis and Government Accountability

AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments, Report No. 16-03, January 2016
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  • As of December 2015, 80% of Florida’s approximately 3.9 million Medicaid recipients received medical and long-term care services from managed care plans.
  • As part of the Agency for Health Care Administration’s (AHCA) efforts to prevent, detect, deter, and recover funds lost to fraud and abuse in the Medicaid Program, the Bureau of Medicaid Program Integrity (MPI) further reorganized to place greater emphasis on fraud and abuse in Medicaid managed care. MPI is establishing new policies and procedures for monitoring managed care program integrity efforts and has developed processes and systems to analyze managed care plan data. In implementing Statewide Medicaid Managed Care, AHCA reorganized the Medicaid Program including contract management processes and oversight of Medicaid managed care plans that support program integrity efforts.
  • MPI uses several methods to identify potential cases of Medicaid overpayment to fee-for-service providers. MPI has continued to recoup overpayments and sanction providers who overbill; during Fiscal Year 2013-14, AHCA levied $2.6 million in fines against 431 providers who had received $15.2 million in overpayments. AHCA also updated its case management system and implemented an advanced data analytics system to enhance detection and recovery efforts.

What were our earlier findings?

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, 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.

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. 18-03 AHCA Continues to Expand Medicaid Program Integrity Efforts; Establishing Performance Criteria Would Be Beneficial,published in January 2018.

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).
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