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James D. Varnado, Director Medicaid Fraud Control Unit (MFCU)Florida Office of the Attorney General

February 6, 2015

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Florida’s Medicaid Fraud Control Unit

� The Florida Attorney General’s Office has been investigating and prosecuting Medicaid fraud since the unit became part of the Attorney General’s Office on July 1, 1994.

Florida’s Medicaid FraudControl Unit

� The Unit is granted authority under both federal and state law (Section 1903 of the Social Security Act, Section 42 of the Code of Federal Regulations and Chapter 409, Florida Statutes).

� The Medicaid program will serve a projected 3.48 million Floridians in SFY 2014-2015.

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Data Mining

� On July 15, 2010, U.S. Department of Health and Human Services granted the Florida MFCU a waiver allowing federal financial participation in data mining activity.

� The current waiver has been extended to December 31, 2015.

Data Mining

� A Memorandum of Understanding between MFCU and the Agency for Health Care Administration (AHCA) was amended to provide a system ensuring the data mining efforts would be coordinated with, and not duplicative of AHCA efforts.

� As of June 30, 2014, the MFCU has submitted 77 data mining projects to the Agency for review.

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Data Mining Process

� AHCA personnel receives written proposals for

data mining projects from MFCU

� AHCA Data Detection Unit reviews

� Purpose of review is to avoid duplicative efforts

� MFCU tracks AHCA responses and data mining

projects

� All responses, outcomes, and analyses are

documented within the MFCU Data Mining file

in the Case Management database.

Data Mining Process

MFCU Analyst and Investigator Collaboration / Adherence to

Waiver protocol to prevent duplicative

efforts

MFCU Analyst

conduct data mining and

analysis

MFCU identifies outliers and Report Results (Possible cases

developed and referrals)

DATA MINING DEVELOPMENT

AND AUTHORIZATION

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Enforcement

� The MFCU has two primary areas of enforcement responsibility. Enforcement in these areas, which includes both criminal and civil enforcement actions, should help prevent, detect, and prosecute these types of misconduct in order to protect the citizens of Florida.

� Fraud perpetrated against the Medicaid Program

� Patient Abuse, Neglect and Exploitation (PANE)

Recoveries

� In FY 2013-14, the total amount for civil

recoveries, which include civil settlements arising from qui tam cases brought under Florida’s False Claims Act, was $96,081,097.

� The total amount for criminal recoveries based upon Medicaid fraud cases was $7,525,738. The total amount of the monies recovered by the MFCU for FY 2013-14 was $103,606,835.

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Recoveries

� The unit has improved efficiency and brought in $15 million in FY 2013-14 in collections to the state’s General Revenue Fund.

� FY 2013-14, for every General Revenue dollar spent, the MFCU generated approximately $4.35 through penalties imposed and interest that was deposited into General Revenue.

Operations

� The Unit’s policy requires a 30-day review of complaints and allegations to determine whether the matter merits further investigation, should be referred to another agency or is unfounded. Case openings occur only when there is a criminal or civil predicate that warrants further investigative activity by the MFCU. During FY 2013-14, the Unit received a total of 1,699 complaints.

� Of those, 1,699 complaints, 261 were opened as operational cases. Of the 1,699 complaints, 807 were related to fraud and 892 were related to PANE allegations.

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Recording and Reporting

• All complaints and cases are electronically recorded, tracked, and reported to include:

• Complaints Opened

• Cases Opened

• Amount of funds recovered

• Number of:

• composition of provider types

• warrants issued for arrests

• referrals for prosecution

• fraud and fraud related convictions

• overpayment and abuse referrals by

MFCU to AHCA

Operations

Fraud

� The following is a list of the top five Medicaid provider types for fraud cases in FY 2013-14, ranked most to least frequent:

� Pharmaceutical Manufacturer

� Pharmacy

� Case Management Agency

� Physician/Medical Doctor

� Home & Community Based Services

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� Medicaid Fraud

Case Update

Case Update

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Case Update

Case Update

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Case Update

PANE

� The following is a list of the top five provider types for PANE cases in FY 2013-14, ranked most to least frequent:

� Facility Employee

� Certified Nursing Assistant

� Care Giver

� Assisted Living Facility

� Skilled Nursing Facility (tied)

� Assisted Care Services (tied)

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Reward Program

Florida’s Medicaid FraudControl Unit

� The Medicaid Fraud Control Unit serves Floridians across the State of Florida in our 8 offices, located in:

� Tallahassee

� Jacksonville

� Pensacola

� Orlando

� Tampa

� West Palm Beach

� Ft. Lauderdale

� Miami

� Medicaid fraud complaints can be reported: Toll Free 1 (866) 966-7226

� Internet Web Site: http://myfloridalegal.com

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James D. Varnado, Director

Medicaid Fraud Control Unit (MFCU)

Florida Office of the Attorney General