State Recovered $50 Million in Medicaid Fraud

By James Call, The Florida Current

Florida spent nearly $17 million fighting Medicaid fraud in a 12-month period ending June 30 and had a net recovery of $50 million. That’s according to the annual Medicaid Fraud and Abuse Report, released Thursday by Attorney General Pam Bondi and Agency for Health Care Administration Secretary Liz Dudek. The fraud investigations resulted in 69 arrests and warrants.

“Our collaborative efforts with the Agency for Health Care Administration have resulted in tremendous financial recoveries on behalf of taxpayers,” Bondi said.

Not mentioned in the release, but available in a 62-page report from the two agencies, is documentation of budget cuts and a decline in some measures of anti-fraud efforts:

  • A 9 percent decline in cases opened, 324, compared to the previous year.
  • A 15 percent decline in referrals for prosecution to 52.
  • A 22 percent decline in recoveries from Medicaid Program Integrity audits to $62.2 million.
  • A 23 percent decline in warrants for arrest to 69.

Home and community based services providers ranked third in the number of fraud cases for FY 2011-12, after physicians and pharmaceutical manufacturers (down one spot from FY 2010-11). In terms of provider abuse, neglect and exploitation, home and community based services providers ranked second following nursing homes (up one spot from 2010-11).

The annual report on the state’s efforts to fight Medicaid fraud shows that 217 providers were terminated from the program and another 229 were denied enrollment or re-enrollment, including 14 home health agencies. That’s an increase from 137 and 78, respectively, from the previous year. Additionally, 84 home health agencies were denied enrollment or reenrollment in the Medicaid program due to considerations or factors that are of program integrity nature, which would include suspected fraud and abuse.

The AG’s Medicaid Fraud Control Unit used data mining to identify circumstances where fraud may be occurring. It has a waiver from the federal government that allows it to access the billing practices of providers, such as hospitals, doctors and pharmacies to identify potentially fraudulent activity.

The report indicates investigators recovered $44.2 million in overpayments, $200,000 in investigation costs, and $5 million in fines and $300,000 in interest payments. AHCA’s Third Party Liability Unit also recovered $141 million.

As it relates to Medicaid home health services, the report found that $2.95 million in overpayments was made to 149 home health care providers for services that were provided contemporaneously to two or more recipients at a single location. These services were to be paid at 100 percent for the first recipient and at a reduced rate for all additional recipients at the same location. Data analysis reporting was conducted and it was determined that overpayments existed due to provider failure to downwardly adjust reimbursements for the additional recipients as required by Florida Medicaid policy.

The report notes the state’s successful efforts to avoid $78.7 million in unnecessary costs because of front-end or prepayment controls with regard to home health and private duty nursing services due to an increase in the denial of services that did not meet the prior authorization criteria. Additionally, the report states that because of the Comprehensive Care Management Project, 4,404 Medicaid recipients had face-to-face assessments completed in order to identify potential overutilization and fraud or abuse of Medicaid services. Further, of the 543 Medicaid providers that received site visits last year, 17 were home health agencies.

Medicaid is the health-care program for the poor and is administered by the state and mostly funded by the federal government. Washington estimates that fraud, mostly in Miami-Dade and Broward counties consumes about $3 billion a year from the Florida program. Medicaid is the second biggest component of the state budget after education, costing about $21 billion a year.

“This report shows both agencies commitment to work together and safeguard this program from major fraud and abuse,” Dudek said. “The agency continues to be forward thinking and is working toward increased use of technology and stakeholder collaboration to aid in fraud fighting efforts.”

More than 3.3 million Floridians receive health care through the Medicaid program.

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