A Glimpse Into AHCA’s Oversight of Fraud, Waste, and Abuse in Florida’s Medicaid Program
The Agency for Health Care Administration (AHCA) is the state agency responsible for the licensure and regulation of health care providers in Florida as well as the administration and regulation of the state Medicaid program. Maintaining compliance with AHCA is extremely important for professionals in the healthcare industry and can oftentimes be challenging to navigate as compliance varies widely depending on the type of healthcare provider and facility involved. One of the primary functions of the AHCA is the oversight and regulation of fraud and abuse of billing and services with respect to Medicaid.
AHCA’s Office of Medicaid Program Integrity (MPI) in the Division of Health Quality Assurance has primary responsibility for administering and overseeing fraud, waste, and abuse prevention and detection efforts for both managed care and fee-for-service systems. MPI is responsible for identifying and investigating providers suspected of fraud, waste, and abuse and ensures that Statewide Medicaid Managed Care contracted health plans comply with Medicaid requirements to prevent, detect, and deter abusive and fraudulent practices. MPI also has the ability to refer cases of suspected provider fraud to the Florida Attorney General’s Medicaid Fraud Control Unit (MFCU) for investigation and prosecution.
MPI uses various methods to identify potential cases of Medicaid overpayments to providers, including conducting routine statistical sampling. MPI will review initial information pertaining to a provider who it suspects has overbilled, and it will open a case and request supporting documentation, such as patient medical records. MPI will then review the documentation provided and issue a decision, indicating the overpayment that the provider must repay, the agency costs for conducting the investigation and the sanctions assessed, if any. Retaining competent legal counsel is essential in this process as if it is not handled correctly, a providers National Provider Identifier (NPI number) may be suspended. With appropriate representation and documentation, a provider can oftentimes negotiate a settlement agreement with AHCA that reflects a reduction in the overpayment amount, or alternatively may elect to challenge the overpayment as a whole, which may result in the overpayment being overturned.
To prevent the issuance of an overpayment demand, it is highly encouraged that providers perform internal audits regularly and affirmatively disclose and repay any overpayments that are self-identified. However, in the event that you or your practice are notified of an overpayment against you, the attorneys at Nicholson & Eastin are highly experienced in interfacing with AHCA and would be happy to assist you with exploring your options and navigating the processes involved. Please give us a call today for a free consultation regarding any questions or concerns you may have with regard to AHCA or any of the functions it serves.