Biennial Review of AHCA's Oversight of Fraud and Abuse in Florida's Medicaid Program
Report 24-03, January 2024
- Statewide Medicaid Managed Care accounts for the majority of state Medicaid expenditures. In Fiscal Year 2022-23 it accounted for 65% of total expenditures, while the fee-for-service program accounted for the remaining 35%.
- Florida's Medicaid enrollment grew substantially in the wake of the COVID-19 pandemic. Federal legislation resulted in enrollment increases in Florida and across the nation. When new congressional legislation ended these changes and decreased federal funding, states were required to return to normal eligibility and enrollment operations and to conduct eligibility redeterminations. Florida began redeterminations in April 2023. As of October 2, 2023, AHCA reported that Florida is estimated to have the ninth lowest procedural termination of coverage rate among states.
- AHCA’s Office of Medicaid Program Integrity has primary responsibility for administering and overseeing fraud and abuse prevention and detection efforts throughout the state’s Medicaid program. In this role, AHCA collaborates with federal and state agencies and managed care organizations (MCOs).
- AHCA has established annual performance targets for program integrity, with specific emphasis on identifying and preventing overpayments within the Medicaid program. AHCA does not have agency performance targets for the detection and prevention of fraud and abuse. Over the past five fiscal years, the agency has failed to meet its targets for identifying overpayments. During Fiscal Year 2021-22, MCOs identified $187.8 million in overpayments, which was a 23% decrease from the previous fiscal year. In recent years, AHCA has shifted primary responsibility for fraud prevention and detection activities to MCOs. Although these organizations have met AHCA’s contractually obligated performance targets for fraud referrals for Fiscal Year 2022-23, the quality and utility of these referrals is unknown.
- A U.S. Department of Health and Human Services, Office of Inspector General report estimated that in August 2020, AHCA made capitation payments on behalf of over 55,000 Medicaid enrollees concurrently enrolled in another state, resulting in $15.8 million in total program costs. An estimated $6.9 million of these payments were made on behalf of recipients no longer residing in Florida.
- In recent years, AHCA has reportedly made efforts to enhance Medicaid program integrity by improving data quality, data analytics, and program oversight. Consistent with prior reports, OPPAGA recommends that AHCA consider taking steps to improve data analytics and program oversight, with particular emphasis on the utility of internal and external performance measures and inter-agency communication.
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