State recoups $162M from Medicaid fraud probe, new report shows

Florida Agency for Healthcare Administration official Melanie Brown-Woofter gives a presentation on the upcoming changes to Florida's Medicaid system on Friday, June 17, 2011, at the Joseph D'Alessandro Building in Fort Myers. At public meetings throughout the state the agency sought public input on legislation passed this spring to move three million Medicaid patients statewide into managed care plans to save millions in dollars. Critics say patients will lose access, quality care and more by the move. David Albers/Staff

Photo by DAVID ALBERS // Buy this photo

Florida Agency for Healthcare Administration official Melanie Brown-Woofter gives a presentation on the upcoming changes to Florida's Medicaid system on Friday, June 17, 2011, at the Joseph D'Alessandro Building in Fort Myers. At public meetings throughout the state the agency sought public input on legislation passed this spring to move three million Medicaid patients statewide into managed care plans to save millions in dollars. Critics say patients will lose access, quality care and more by the move. David Albers/Staff

Florida Attorney General Pam Bondi and Gov. Rick Scott talk to the media about his plans to remove voters from the election roles during a ceremonial bill signing in Miami on Tuesday, June 12, 2012. (AP Photo/J Pat Carter)

Florida Attorney General Pam Bondi and Gov. Rick Scott talk to the media about his plans to remove voters from the election roles during a ceremonial bill signing in Miami on Tuesday, June 12, 2012. (AP Photo/J Pat Carter)

Gov. of Florida, Rick Scott.

Gov. of Florida, Rick Scott.

— The state recouped $162 million from Medicaid fraud investigations last year, a 47 percent increase from $110 million that was recovered in 2011, according to new data released Thursday.

The state Agency for Health Care Administration and the Attorney General's Office released its annual Medicaid fraud report, which details their combined handling of complaints and investigations of Medicaid fraud.

The probes include false payments, double billing and claims for services never rendered to clinics, surgery centers, pharmacies, nursing homes and hospitals.

Of the total recovered last year, $144 million was recouped as a result of civil settlements from whistle-blower cases filed under the state's False Claims Act. The rest was recovered from criminal investigations.

The state's $22 billion Medicaid program is the fourth largest in the United States and serves 3.3 million Floridians who are low income, disabled or elderly. The Medicaid program is one-third of the state's budget.

Fraud in the Medicaid system is significant. The state has 210 full-time employees assigned to the fraud unit and spent $16.7 million last year on investigations.

"Our collaborative efforts with the Agency for Health Care Administration (ACHA) have resulted in tremendous financial recoveries on behalf of taxpayers," Attorney General Pam Bondi said in a news release. "We will continue to work steadfastly toward the shared goal of ensuring Medicaid dollars go to helping the needy rather than to those who defraud the system."

The report was sent last week to Gov. Rick Scott.

"We take every taxpayer dollar seriously, and are always working to crack down on fraud," Scott's office said in a statement. "This recoupment of millions of dollars serves as a testament to the great partnership between ACHA and the Attorney General's office and I applaud their success in cracking down on Medicaid fraud and abuse through improved processes and technologies."

The bulk of fraud investigations originate from complaints. The state received 1,420 complaints last year and opened 324 investigations, the report shows. That's down from 1,755 complaints in 2011, when 356 cases were opened.

Most of the investigations are opened against doctors, pharmaceutical manufacturers, home health providers and pharmacies. Arrest warrants were issued for 69 individuals last year, down from 90 arrest warrants the year before.

A major focus has been against "pill mill" operations where the state has worked with the Florida Department of Law Enforcement and the federal Medicare program to crack down on clinics, doctor offices and pharmacies that prescribe narcotics, namely oxycodone, hydrocodone and Xanax, to drug seekers.

The state fraud unit terminated the prescribing rights to 437 operations that were deemed "pill mills," according to the state.

The Collier County Sheriff's Office did not work with the state on any local "pill mill" operations, sheriff's spokeswoman Karie Partington said.

"We have not reported any to the state or investigated any on our own," she said.

The state denied more than 7 million fee-for-service pharmacy claims representing $1 billion in claims but the report points out that many of them could have been resubmittals due to technical issues and 25 percent of the claims may be paid.

South Florida historically is where many fraud investigations are conducted but the latest data shows the state's north region, encompassing the areas around Jacksonville to Tallahassee, is where the 105 cases were opened in 2012. That compares to 50 cases opened in South Florida.

Collier County is included in the south region, but the state report does not highlight any significant investigations of Medicaid fraud that may have taken place in Collier. Lee County is part of the state's central office with offices in Orlando and Tampa. Similarly, the latest report does not include any major cases in Lee.

Because of prior authorization requirements before services can be rendered to patients, the state is saving about 3 percent each year on "cost avoidances."

The report said $97 million was denied to hospitals in 2010, the last year that data was available, and $78 million was denied last year for private-duty nursing care, according to the data.

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