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Office of Program Policy Analysis and Government Accountability

AHCA Continues to Improve Medicaid Program Data Quality and Oversight; Additional Improvements Needed in Use of Data, Report No. 20-04, January 2020
 
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  • AHCA’s Office of Medicaid Program Integrity (MPI) is primarily responsible for administering and overseeing waste, fraud, and abuse prevention and detection efforts for both managed care and fee-for-service. Other entities within AHCA, including the Division of Medicaid, play a role in this effort.
  • Since OPPAGA’s 2018 review, AHCA has made improvements to its centralized model for managed care oversight. Oversight would be further improved by AHCA formalizing communication regarding oversight responsibilities and reorganizing the Medicaid Business Intelligence Unit.
  • MPI has taken steps to monitor managed care plans but lacks specific benchmarks to assess plan antifraud performance and should develop reports that provide context for plan antifraud activities. MPI should also create documentation for its Fraud and Abuse Case Tracking System to ensure that all system users consistently enter investigative information and to assist in analyzing the information in the database.
  • Although AHCA continues efforts to improve data quality and oversight, it does not currently have a plan or a process in place to use encounter data or fee-for-service claims data to comprehensively monitor trends in the Medicaid program. Continuing issues with the quality of the encounter data reported to the Florida Medicaid Management Information System present barriers to agency efforts to ensure program integrity for managed care, and both fee-for-service and managed care program oversight are hindered by a lack of complete data.

Which Government Program Summaries contain related information?

Agency for Health Care Administration
Health Quality Assurance
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.
  • 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. 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.

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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