Florida Did Not Suspend Medicaid Payments to Some Providers That Had Credible Fraud Allegation Cases in Accordance With the Social Security Act

The Florida Agency for Health Care Administration (State agency) did not always suspend Medicaid payments to providers that had credible fraud allegation cases in accordance with the Social Security Act. Of the 95 cases that we reviewed, the State agency applied a good-cause exception not to suspend payments for 1 case; and it either suspended, pursued recovery, or otherwise did not make Medicaid payments to providers related to 40 other cases.

For the remaining 54 cases, the State agency did not suspend Medicaid payments for 4 cases totaling $13.8 million ($8.1 million Federal Share). Furthermore, for one case with a completed investigation that resulted in a civil settlement, the State agency did not provide documentation to support that it returned the Federal share of $237,000 to the Federal Government. Finally, for 49 cases for which the Florida Medicaid Fraud Control Unit (MFCU) had completed its investigation and payment suspension was no longer proper, the State agency had not suspended Medicaid payments totaling $70.3 million ($40 million Federal share) when a fraud investigation was pending.

We recommended that the State agency (1) refund $8.1 million to the Federal Government; (2) refund $237,000 to the Federal Government related to one case for which the State agency did not provide documentation to support that it returned the Federal share to the Federal Government; and (3) update its policies and procedures to ensure that it adheres to the MOU and complies with the Act to suspend Medicaid payments to providers with credible fraud allegations, which could have prevented $70.3 million ($40 million Federal share) from being at risk.

In written comments on our draft report, the State agency partially concurred with our second recommendation but did not concur with our calculation of the Federal share. In addition, the State agency did not concur with our first or third recommendations. After considering the State agency's comments on our draft report, we maintain that all of our findings and recommendations are valid.