Office of Program Policy Analysis and Government Accountability
Office of Program Policy Analysis and Government Accountability

Biennial Review of AHCAs Oversight of Fraud, Waste, and Abuse in Florida's Medicaid Program

Report 22-03, January 2022

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Report Summary

  • The Agency for Health Care Administration’s (AHCA) Division of Medicaid provides health care for low-income families and individuals and assists the elderly and people with disabilities with nursing facility care costs and other medical and long-term expenses. Statewide Medicaid Managed Care accounts for the majority of state Medicaid expenditures, but fee-for-service payments still account for over one-third of total expenditures.
  • AHCA’s Office of Medicaid Program Integrity is primarily responsible for administering and overseeing fraud, waste, and abuse prevention and detection efforts for both managed care and fee-for-service. Other entities within AHCA, including the Division of Medicaid, assist the office in this effort.
  • Due to the COVID-19 pandemic, AHCA has implemented a number of Medicaid flexibilities since March 2020 to ensure access to health care services during a public health emergency. According to recent federal reports, changes in rules and regulatory processes increase risks of fraud, waste, and abuse during public health emergencies; however, AHCA has not developed additional oversight procedures in response to flexibilities implemented by the agency.
  • Consistent with several recommendations from OPPAGA’s 2020 report, AHCA enhanced oversight and monitoring of Medicaid systems in several areas. The agency improved intra-agency coordination of managed care plan oversight, enhanced data system documentation, developed a performance target for fraud reporting, enhanced provider screening processes, implemented policies to refine service categories and procedure codes, and continued conducting validation studies. Improvements are still needed in several areas, including documentation of contract monitoring methods and data documentation, antifraud activity tracking and data analysis, and data quality and use of encounter data. 

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