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OPPAGA text logo with graphic of FL historic capitol

Medicaid Program Integrity Recovers Overpayments in Fee-For-Service and Monitors Fraud and Abuse in Managed Care

Report 14-05, January 2014

Report Summary

  • 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.

Related Reports
  1. AHCA Continues to Improve Medicaid Program Data Quality and Oversight; Additional Improvements Needed in Use of Data
    Report 20-04 January 2020
  2. AHCA Continues to Expand Medicaid Program Integrity Efforts; Establishing Performance Criteria Would Be Beneficial
    Report 18-03 January 2018
  3. AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments
    Report 16-03 January 2016
  4. Agency for Health Care Administration Continues Efforts to Control Medicaid Fraud and Abuse
    Report 11-22 December 2011
Copies of this report in print or alternate accessible format may be obtained by email OPPAGA@oppaga.fl.gov, telephone (850) 488-0021, or mail 111 W. Madison St., Room 312 Tallahassee, FL 32399-1475.
Medicaid fraud and abuse, medicaid program integrity, medicaid managed care, medicaid managed care accountability