$70.3 Million in Medicaid Payments Were Made to Providers With Fraud Allegations

Payments to providers who overbilled or defrauded program should be suspended, according to audit

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May 1, 2017

The state of Florida made $70.3 million in Medicaid payments to providers who had fraud allegations against them, according to an audit from the inspector general.

The Office of Medicaid Program Integrity is charged with investigating and auditing providers that are thought to have defrauded or overbilled the state's Medicaid program. Since 2011, if a provider has a credible fraud allegation, the state must suspend all Medicaid payments to that provider.

The auditors found that Florida did not always suspend payments to providers in these cases. The inspector general reviewed 95 cases and found that in more than half of them, Florida did not suspend Medicaid payments totaling $70,257,156 when there was a fraud investigation pending, putting these Medicaid funds at risk.

There were four cases in which fraud investigations were pending and the state did not suspend Medicaid payments. These payments totaled $13,827,876, including a federal share of $8,056,973 that was not eligible for reimbursement.

"The state agency repeatedly failed to suspend payments when there was a credible fraud allegation because it neither updated its policies and procedures to reflect the requirements of the Act nor adhered to the [memorandum of understanding] that required the state agency to suspend payments 45 days from the referral date for cases it referred to the [Florida Attorney General's Medicaid Fraud Control Unit]," the auditors said.

The auditor recommended that the $8,056,973 be refunded to the federal government and that the state update its policies and procedures to ensure that Medicaid payments be suspended if there are credible fraud allegations pending so as to prevent payments from being at risk.

The state of Florida said in response to the audit report that it "suspected that the providers' activities were suspicious" but the actions did not rise to the level of credible fraud allegations.

The office of the inspector general differed. "We maintain that all of our findings and recommendations are valid," the inspector general said. "We disagree with the State agency's position that the referrals to the [Florida Attorney General's Medicaid Fraud Control Unit] of suspicious fraud did not constitute credible fraud allegations."

Published under: Fraud , Medicaid , Welfare