Originally Posted - December 30, 2006

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TALLAHASSEE-The Florida Agency for Health Care Administration (AHCA), together with the Office of the Attorney General, has released the state's annual report on Medicaid fraud and abuse.

The report outlines the activities of AHCA's Bureau of Medicaid Program Integrity (MPI) and the Medicaid Fraud and Control Unit (MFCU) of the Office of the Attorney General in detecting fraudulent activities and overpayments to health care providers, recovering overpayments and taking administrative actions to prevent abusive behavior within the Medicaid system.

"The hard work of the MPI and MFCU units protects the integrity of Florida's Medicaid program and ensures taxpayers' money is applied appropriately and responsibly," said AHCA Secretary Christa Calamas. "Closer monitoring of Medicaid billing, aggressive prevention measures and increased efforts to recover overpayments have strengthened the state's ability to combat fraud and abuse more than ever before."

Calamas was formerly assistant counsel to Gov. Jeb Bush and represented the Govenor in the Terri Schiavo case when Bush asked U.S. District Judge Richard A. Lazzara for permission for the governor to appear as a friend of the court and to file an amicus curiae, or friend of the court, brief supporting the preliminary injunction sought by Terri's parents in October 2003, the second time when the death order of Pinellas County Court Judge George Greer was carried out.

Ultimately the state Legislature passed Terri's Law which resulted in the reinsertion of disabled woman's feeding tube six days after it had been removed but the courts later struck down the law as being unconstitutional.

Bush appointed Calamas to serve as AHCA secretary in July 2006.

Prevention is key to controlling Medicaid fraud and abuse in Florida. During fiscal year 2005-2006, MPI prevention efforts resulted in avoided costs or overpayments of $37 million. During the last three years, $100 million in overpayments was prevented. Prevention techniques employed by MPI include prepayment reviews to identify improper claims and deny payment, recommendations for termination of providers suspected of misusing the Medicaid program, and declining reimbursement for prescription drugs prescribed by practitioners terminated from the Medicaid program.

In 2005-2006, 245 providers were placed on prepayment review. This prevented the payment of $5.5 million to abusive providers. AHCA terminated 194 providers from the program last fiscal year, a 600% increase since 2002-2003, when 28 providers were terminated.

AHCA's recovery of overpayments has also increased during the past year. MPI recovered $28 million in overpayments - an increase of 37 percent from the prior fiscal year. The recovery of overpayments is the result of comprehensive investigations and audits of Medicaid providers. Last year, more than 1,200 comprehensive audits of Medicaid providers were completed.

In addition to the efforts of MPI, AHCA's Division of Medicaid has implemented various program and system initiatives for preventing fraud and abuse. These initiatives range from provider site visits - ensuring applicants meet enrollment criteria - to identifying errors in payments, inappropriate billing, and others factors that contribute to the overall payment accuracy rate.

Among the most successful efforts of the Division of Medicaid has been the work of the Third Party Liability Unit. This unit is responsible for identifying and recovering funds for claims paid by Medicaid for which a third party was liable. Since fiscal year 2002- 2003, recovery performance in the area of third party liability increased by 70% in total recoveries, with $112 million recovered in fiscal year 2005-2006. Examples of third parties include insurance companies, claims for which Medicare may be liable, recipient estates and casualty settlements.

AHCA's efforts to control fraud and abuse have been enhanced by its partnership with the MFCU of the Office of the Attorney General. Suspected fraud is referred to the MFCU for investigation of possible civil and/or criminal violations.

MFCU investigations and prosecutions involve fraudulent health care schemes that include phantom billing (when the medical provider bills for services not rendered) and upcoding (when a provider bills for a more costly service than that provided), in addition to more complicated conspiracies to manipulate pharmaceutical prices and supply of drugs in Florida. In 2005-2006, AHCA referrals to the Attorney General increased nearly 300% since 2002-2003.

Working to improve access to affordable, quality health care to all Floridians, the state Agency for Health Care Administration administers Florida's $16.6 billion Medicaid program, licenses and regulates more than 32,000 health care providers and 37 health maintenance organizations and publishes health care data and statistics.

For a complete copy of the annual Medicaid fraud and abuse report please visit http://ahca.myflorida.com/Publications/forms/MPI_REPORT.pdf. 12-30-06

© 2006 North Country Gazette