As of November 2025, there were approximately 4.0 million persons enrolled in Florida Medicaid. Seventy-three percent of enrollees received services through the Statewide Medicaid Managed Care (SMMC) program, while 27% received services through the fee-for-service (FFS) system. As of November 2025, there were 347,530 active providers across the eight managed care organizations (MCOs) operating within the SMMC program.

The Agency for Health Care Administration’s (AHCA) Office of Medicaid Program Integrity (MPI) is responsible for fraud and abuse monitoring and collaborates with federal and state entities to support prevention, detection, and deterrence activities. MCOs support these efforts and are contractually required by AHCA to report suspected or confirmed provider fraud to MPI and the Florida Medicaid Fraud Control Unit (MFCU) and suspected or confirmed abuse to MPI.

During OPPAGA’s review period (Fiscal Years 2022-23 and 2023-24), MPI and MCOs had mixed results in meeting fraud detection and prevention performance targets. MPI did not meet the detection-based performance target for overpayments identified but exceeded prevention-based performance targets for overpayments prevented. MCOs have not consistently met the detection-based performance target for fraud referrals.

According to national entities, collaboration is critical to program integrity and referral quality. MPI communicates regularly with the MCOs, but quarterly meetings with MFCU to discuss fraud cases are recommended. In addition, while AHCA reported that fraud referral quality has improved since OPPAGA’s last review, MCO staff indicated that further improvements may be achieved through additional communication and collaboration.

To address issues related to measuring efforts to prevent, detect, and deter fraud and abuse, OPPAGA recommends that AHCA take steps to improve the utility and comprehensiveness of its performance measures related to program integrity and collaborate with MFCU to specify the elements that define a quality referral.

Biennial Review of AHCA's Oversight of Fraud and Abuse in Florida's Medicaid Program
Report 24-03 January 2024
AHCA Continues to Improve Medicaid Program Data Quality and Oversight; Additional Improvements Needed in Use of Data
Report 20-04 January 2020
AHCA Continues to Expand Medicaid Program Integrity Efforts; Establishing Performance Criteria Would Be Beneficial
Report 18-03 January 2018
AHCA Reorganized to Enhance Managed Care Program Oversight and Continues to Recoup Fee-for-Service Overpayments
Report 16-03 January 2016

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.