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OPPAGA text logo with graphic of FL historic capitol

AHCA Continues to Expand Medicaid Program Integrity Efforts; Establishing Performance Criteria Would Be Beneficial

Report 18-03, January 2018

Report Summary

  • Since OPPAGA's 2016 review, the Bureau of Medicaid Program Integrity (MPI) has developed two review checklists, reestablished on-site monitoring, and redesigned the managed care annual fraud and abuse activity report. From February to May 2017, MPI conducted annual monitoring reviews of all the managed care health plans using a new review checklist that considers health plan compliance with contractual, state, and federal guidelines. While MPI continues to identify and collect overpayments to fee-for-service providers, its data analytics vendor did not perform as expected and the contract was not renewed.
  • The Agency for Health Care Administration could further improve its program integrity efforts by establishing evaluation criteria and performance measures. MPI's review of managed care plans does not include performance standards. In addition, the agency has not identified useful measures to evaluate MPI's performance. Further, several recent state and federal reviews suggest the Bureau of Medicaid Program Integrity could improve its performance. The agency recently moved the bureau from the Office of the Inspector General to the Division of Health Quality Assurance, which may provide an opportunity to consider the bureau's current fee-for-service focus.

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 Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments
    Report 16-03 January 2016
  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, Medicaid program integrity, waste fraud and abuse, prevention and detection, managed care,