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AHCA Continues to Improve Medicaid Program Data Quality and Oversight; Additional Improvements Needed in Use of Data

Report 20-04, January 2020

Report Summary

  • AHCA's Office of Medicaid Program Integrity (MPI) is primarily responsible for administering and overseeing waste, fraud, and abuse prevention and detection efforts for both managed care and fee-for-service. Other entities within AHCA, including the Division of Medicaid, play a role in this effort.
  • Since OPPAGA's 2018 review, AHCA has made improvements to its centralized model for managed care oversight. Oversight would be further improved by AHCA formalizing communication regarding oversight responsibilities and reorganizing the Medicaid Business Intelligence Unit.
  • MPI has taken steps to monitor managed care plans but lacks specific benchmarks to assess plan antifraud performance and should develop reports that provide context for plan antifraud activities. MPI should also create documentation for its Fraud and Abuse Case Tracking System to ensure that all system users consistently enter investigative information and to assist in analyzing the information in the database.
  • Although AHCA continues efforts to improve data quality and oversight, it does not currently have a plan or a process in place to use encounter data or fee-for-service claims data to comprehensively monitor trends in the Medicaid program. Continuing issues with the quality of the encounter data reported to the Florida Medicaid Management Information System present barriers to agency efforts to ensure program integrity for managed care, and both fee-for-service and managed care program oversight are hindered by a lack of complete data.

Related Reports
  1. AHCA Continues to Expand Medicaid Program Integrity Efforts; Establishing Performance Criteria Would Be Beneficial
    Report 18-03 January 2018
  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, Statewide Medicaid Managed Care, Fee-for-Service, encounter data, claims data, Medicaid fraud and abuse, Florida Medicaid Management Information System, FMMIS, managed care organizations, managed care plans