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OPPAGA text logo with graphic of FL historic capitol

AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments

Report 16-03, January 2016

Report Summary

  • 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.

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. Medicaid Program Integrity Recovers Overpayments in Fee-For-Service and Monitors Fraud and Abuse in Managed Care
    Report 14-05 January 2014
  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