Report: Florida collected $45 million in Medicaid overpayments and criminal, civil penalties last year

Florida recovered more than $22 million in civil and criminal penalties stemming from Medicaid fraud and abuse in Fiscal Year 2020-21. The state also clawed back $23 million in Medicaid overpayments to providers, according to a new state report.

The report — which looked at the state’s efforts to go after Medicaid fraud — was developed by the Agency for Health Care Administration (AHCA) and the Office of the Attorney General, which work together to go after scammers trying to rip off the $34 billion health care program that provides services to the state’s poor, elderly and disabled.

The AG’s office houses what’s called the Medicaid Fraud Control Unit, which is charged with investigating and prosecuting Medicaid fraud and abuse cases. Meanwhile, Medicaid Program Integrity is housed at AHCA, as is the state’s Medicaid program.

The report shows the Medicaid Fraud Control Unit received 7,605 complaints between July 1, 2020, and June 30, 2021, which is about 2,000 fewer complaints it received the previous year.

The unit opened 415 cases during the year, of which 221 involved provider fraud. The fraud unit had 1,264 active cases in FY 2020-21. It often takes more than a year to investigate fraud and the number of opened cases annually has no connection to the number of cases disposed annually.

After an investigation, the AG’s office determines whether to pursue criminal prosecution or take civil cause.

In FY 2020-21, the fraud unit closed 444 cases. Of those, 211 involved Medicaid fraud investigations and 233 involved PANE cases (Patient Abuse, Neglect and Exploitation). PANE cases usually stem from the Department of Children and Families Adult Protective Services Unit. PANE cases focus on timely criminal prosecution and protection of clients.

Meanwhile, the unit referred 33 cases for prosecution during the year, 21 of which were fraud cases involving providers.

State law defines Medicaid fraud as an “intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to herself or himself or another.”

Abuse is defined as “provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care.”

AHCA and the AG’s office are required to annually submit a report to the Legislature by Jan. 15 describing, among other things, the number of Medicaid fraud and abuse cases opened and investigated each year; the sources of the cases opened; the disposition of the cases closed each year; and the dollar amount of Medicaid overpayments recovered each year.

The $22.7 million-plus in civil and criminal recoveries collected in FY 2020-21 by the Medicaid Fraud Control Unit outpaces the $11.8 million that was collected the previous fiscal year. However, the $23 million recovered in Medicaid overpayments by Medicaid Program Integrity is less than the $30 million in overpayments it recovered the year before.

The MPI focuses on five areas: fraud prevention, fraud detection, Managed care plans, payment recoupment and operational activities.

According to the report, MPI investigated 3,682 cases of potential fraud during FY 2020-21, including 2,858 that were opened during the year. That’s a dip from the 3,434 cases opened during FY 2019-20.

MPI made 72 formal referrals regarding managed care plans to counterparts at the AG’s office. That’s an increase from the 48 referrals MPI made the year before.

Meanwhile, 820 providers were banned from enrolling or re-enrolling in the Medicaid program in FY 2020-21 due to fraud and abuse or suspected fraud and abuse. Of those, 398 were behavioral analysis providers, according to the report.