strike force annual report

Transcription

1 strike force annual report October 1, 2012 Respectfully Submitted by Chief Financial Officer Jeff Atwater, Chairman

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3 STRIKE FORCE MEMBERS Chairman, Jeff Atwater, Chief Financial Officer, Florida Department of Financial Services Gerald Bailey, Commissioner & Executive Director, Florida Department of Law Enforcement Vice Chair, Pam Bondi, Attorney General, Florida Office of Attorney General Elizabeth Dudek, Secretary, Florida Agency for Health Care Administration David Wilkins, Secretary, Florida Department of Children & Family Services John H. Armstrong, M.D., FACS, State Surgeon General, Florida Department of Health Katherine Fernandez-Rundle, State Attorney, Eleventh Judicial Circuit (Miami-Dade) Sheriff David Gee, Hillsborough County Sheriff s Office Dennis Jones, Chief of Police, City of Tallahassee Police Department Sheriff Ric L. Bradshaw, Palm Beach County Sheriff s Office Juan Jesus Santana, Division Chief, Miami-Dade Police Department

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5 ABOUT THE STRIKE FORCE The 2010 Florida Legislature established the Medicaid and Public Assistance Fraud Strike Force (Strike Force) under Section , Florida Statutes. The Legislature based the formation of this Strike Force upon a finding that there is a need to develop and implement a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud, Section (1), Florida Statutes. Responsibilities of the Strike Force The legislation directed that the Strike Force serve in an advisory capacity and provide recommendations and policy alternatives to help achieve the overall mission of the Strike Force: to eliminate Medicaid and public assistance fraud and to recover state and federal funds, Section (2), Florida Statutes. To help the Strike Force achieve its purpose, in Section (6)(a), Florida Statutes the Legislature authorized the Strike Force to advise the Chief Financial Officer on initiatives that include, but are not limited to: 1. Conducting a census of local, state, and federal efforts to address Medicaid and public assistance fraud in this state, including fraud detection, prevention, and prosecution, in order to discern overlapping missions, maximize existing resources, and strengthen current programs. 2. Developing a strategic plan for coordinating and targeting state and local resources for preventing and prosecuting Medicaid and public assistance fraud. The plan must identify methods to enhance multiagency efforts that contribute to achieving the state s goal of eliminating Medicaid and public assistance fraud. 3. Identifying methods to implement innovative technology and data sharing in order to detect and analyze Medicaid and public assistance fraud with speed and efficiency. 4. Establishing a program to provide grants to state and local agencies that develop and implement effective Medicaid and public assistance fraud prevention, detection, and investigation programs, which are evaluated by the strike force and ranked by their potential to contribute to achieving the state s goal of eliminating Medicaid and public assistance fraud. The grant program may also provide startup funding for new initiatives by local and state law enforcement or administrative agencies to combat Medicaid and public assistance fraud. 5. Developing and promoting crime prevention services and educational programs that serve the public, including, but not limited to, a wellpublicized rewards program for the apprehension and conviction of criminals who perpetrate Medicaid and public assistance fraud. 6. Providing grants, contingent upon appropriation, for multiagency or state and local Medicaid and 5

6 public assistance fraud efforts, which include, but are not limited to: a. Providing for a Medicaid and public assistance fraud prosecutor in the Office of the Statewide Prosecutor. b. Providing assistance to state attorneys for support services or equipment, or for the hiring of assistant state attorneys, as needed, to prosecute Medicaid and public assistance fraud cases. c. Providing assistance to judges for support services or for the hiring of senior judges, as needed, so that Medicaid and public assistance fraud cases can be heard expeditiously. The legislation also authorized the Strike Force to receive periodic reports from state agencies, law enforcement officers, investigators, prosecutors, and coordinating teams regarding Medicaid and public assistance criminal and civil investigations. Such reports may include discussions regarding significant factors and trends relevant to a statewide Medicaid and public assistance fraud strategy. Strike Force Supports The Strike Force is supported by three full-time positions. The staff includes an Executive Director who has a strong background in Medicaid fraud and criminal investigation, having worked in the Medicaid Fraud Control Unit (MFCU) in the Office of Attorney General (OAG), in Worker s Compensation fraud and as Inspector General for the Agency for Persons with Disabilities, a state Medicaid agency. The Exe cutive Director is supported by two positions - one to provide support in the areas of research, analysis, planning and funding strategies and a second to provide all administrative support. Other supports provided for the Strike Force include routine grant searches by Strike Force staff and a Web site ( In addition, two small consulting contracts have provided a high level business process map of major fraud prevention and detection processes across the involved agencies and the services of an economic consultant to assist with a determination of the rate of fraud in the Florida Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps. 6

7 In accordance with Section , Florida Statutes, The strike force shall annually prepare and submit a report on its activities and recommendations, by October 1, to the President of the Senate, the Speaker of the House of Representatives, the Governor, and the chairs of the House of Representatives and Senate committees that have substantive jurisdiction over Medicaid and public assistance fraud. This report is intended to meet this obligation without duplicating the information contained in the annual report on The State s Efforts to Control Fraud and Abuse prepared by the Agency for Health Care Administration (AHCA) and the Medicaid Fraud Control Unit (MFCU) within the Office of Attorney General (OAG). That report should be considered a reference source for more detailed information about the activities, processes, and operations of AHCA and MFCU. This report, instead, focuses on what the Strike Force has done in the past year, information that has been gathered and recommendations being proposed to support a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud, as required in Section (1), Florida Statutes. Every effort has been made to ensure that data contained in this report are accurate as of the date this report was written. Because information used in generating data or making projections is routinely updated, minor inconsistencies between information in this report and that contained in other reports will result. ABOUT THIS REPORT Acronyms Used in this Report The following provides a reference guide to acronyms that are used frequently throughout this report. ACCESS AHCA DCF DFS DOH DPAF EBT FDLE MFCU MPI OAG PBI SLEB SNAP USDA Automated Community Connection to Economic Self Sufficiency (in DCF) Florida Agency for Health Care Administration Florida Department of Children & Family Services Florida Department of Financial Services Florida Department of Health Division of Public Assistance Fraud (in DFS) Electronic Benefit Transfer Florida Department of Law Enforcement Medicaid Fraud Control Unit (in OAG) Bureau of Medicaid Program Integrity (in AHCA) Office of Attorney General Office of Public Benefit Integrity (in DCF) State Law Enforcement Bureau (DPAF in DFS) Supplemental Nutrition Assistance Program (in USDA) U. S. Department of Agriculture 7

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9 Grants COMMITTEES AND MEMBERS The Strike Force established a Grants Committee in July 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this Committee are: 1. To research and identify appropriate grant programs for the Strike Force and/or its partners to pursue. 2. To assist with pursuing funding opportunities for the Strike Force and/or the partner agencies. 3. To provide guidance on the development of a grant initiative for the Strike Force in which the Strike Force is the grantor. 4. To review applications and make recommendations to the Strike Force for grant awards under the Strike Force grant initiative. The following members of the committee were designated by Strike Force members to represent their agencies: Jo Landa Givens, AHCA Cynthia Godbey, DFS Paula Holder/Janice Hays, OAG Sheri Lynn, DCF Phil Street, DOH Clayton Wilder, FDLE In the past year, the Grants Committee facilitated the submission of two funding requests for about $3.89 million which are still pending funding decisions. An additional three potential funding sources were referred to AHCA and one was referred to DOH. The Grants Committee has also undertaken discussions about the possibility of overseeing a granting initiative by the Strike Force. They have reviewed sample grant application forms and discussed evaluation criteria for proposals that may be submitted. Mapping The Strike Force also established a Mapping Committee in July 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this Committee are: 1. To advise the Strike Force in the development of a tool that can provide a succinct picture of the anti-fraud processes in the Medicaid and public assistance service systems. 2. To advise the Strike Force on priorities for mapping business processes on vulnerable points within the Medicaid and public assistance service systems. 3. To follow through with mapping vulnerable points within the Medicaid and public assistance service systems. Guidance from this group helped direct the work of Advanced Systems Design, a business consulting firm, to 9

10 develop a high level visual representation of the prevention, detection, investigation and recoupment of funds processes across the agencies that are primarily responsible for combating fraud in the Medicaid and public assistance service systems. Based upon that work, the Committee recommended that the next mapping project focus on mapping the processes involved in determining beneficiary eligibility determination through Automated Community Connection to Economic Self-Sufficiency (ACCESS). That project is currently underway. The following members of this committee were designated by Strike Force members to represent their agencies: Randy Burkhalter, DFS Annette Cohen/James D. Varnado, OAG Mike Magnuson, AHCA Charlene Willoughby, DOH Fred Young, DCF Legislative and Policy The Strike Force then established a Legislative and Policy Committee in August 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this Committee are: 1. To develop legislative platforms that the Strike Force can advocate that will support the implementation of Strike Force initiatives and strategies. 2. To review initiatives of other states that address Medicaid and public assistance fraud. 3. To make proposals to the Strike Force regarding innovative policy initiatives. This committee reviewed and recommended adoption of the recommendations contained in the first Annual Report to the Legislature from the Strike Force. The Committee is currently reviewing issues of concern to Strike Force member agencies in order to define a platform of issues that the Strike Force can collectively advocate for in the 2013 Legislative session. The following members of this committee were designated by Strike Force members to represent their agencies: Michael Cantens, DOH Chris Chaney, AHCA Lynn Dodson, FDLE Andrew Fay/Rob Johnson, OAG Amanda Huston, DCF Logan McFadden, DFS Technology The Strike Force also established a Technology Committee in August 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this Committee are: 1. To interact with the Interagency Technology working group to guide policy regarding the implementation of technology solutions throughout the Medicaid and public assistance service systems. 2. Provide advice/guidance on specific technology options. This committee has met a number of times during the last year and has proven an invaluable vehicle for information sharing among the Chief Information Officers of the Strike Force member agencies. They have exchanged information on tools being used or that could be used to advance efforts to fight fraud in Medicaid and public assistance programs. Most recently, the Committee worked together to draft a Request for Information that will be issued in an effort to gather information about anti-fraud technologies and solutions that are available from the private sector. The information gathered will be compiled and distributed to the Strike Force agencies as a reference source. The following members of this committee were designated by Strike Force members to represent their agencies: Bob Dillenschneider, DOH Tammy Joiner-Philcox, OAG Terry Kester, DFS Penny Kincannon, FDLE David Taylor, DCF Scott Ward, AHCA 10

11 STRIKE FORCE MEETINGS The minutes and materials from meetings of the Strike Force can be found on the website at: flstrikeforce.com. These meetings provide an opportunity for the leadership of the Strike Force member agencies to provide updates and share information on advances being made in our efforts to prevent, detect and recoup improper payments as a result of fraud. In addition, the Executive Director researches topics of potential interest and communicates them to the members. Here is a summary of the meetings held in the past year. February 2, 2012 The U. S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) gave a presentation on their role relative to Medicaid services. They provided information on the activities of their agency in identifying waste and abuse, which focuses on processes employed by Medicaid agencies, as well as investigating allegations of fraud. The Office of Investigations provided information on the latter. This last year was one of the biggest for HHS OIG with regard to investigations and Florida represented about 20% of the criminal cases prosecuted. The Federal Middle and Southern districts of Florida received the lion s share of qui tam cases (civil relator lawsuits) filed. These qui tam cases are handled in cooperation with the Florida MFCU. In addition, two of the nine national Health Care Fraud Prevention and Enforcement Action Teams (HEAT) are located in Florida. HEAT teams are a joint initiative between HHS and the Department of Justice and work in cooperation with the MFCUs targeting Medicare and Medicaid fraud. One positive outcome from the HEAT teams has been an increase in the number of cases worked jointly between federal, state and local agencies. They have led to other geographically targeted task forces and working groups around the state creating health care partnerships that can benefit investigations. The Medi-Medi project was one of these in which the Medicaid contractor looks at dual enrollees on a regular basis to detect instances of duplicate billing and then refers suspected fraud to the MFCU or to HHS OIG, as appropriate. They have also collaborated with the Regional Drug Enforcement (Pill Mill) Strike Forces. The HHS OIG Office of Audit Services discussed their responsibilities for auditing processes. They recently looked at how Florida calculates their administrative costs and should be issuing a report on those findings soon. In a previous recent audit, they looked at payments to excluded or terminated providers. It was reported that Florida has good controls in place to prevent waste and abuse in that regard. The Strike Force also heard from the Inspector General from the Agency for Persons with Disabilities (APD) who reported on concerns over fraud with the Medicaid waiver programs that provide services to APD s clientele. In the last year, the number of clients served by APD declined while costs increased. Given these increasing costs and estimates by the Association of Certified Fraud Examiners that 5-10% of total program costs are lost to fraud, fraud is a serious concern for APD. He shared the following recommendations with the Strike Force: When an agency determines that a provider has recently been or is being investigated by another agency, they need to share their findings on that provider; 11

12 We need to instill in our managers that they are responsible for fraud detection; We need to require all employees to report fraud and suspected fraud; and We need to hold managers responsible for fraud that occurs in their areas. August 8, 2012 In preparation for the move to statewide Medicaid managed care, the Strike Force heard presentations from the Office of Insurance Regulation (OIR) and the Bureau of Health Systems Development within the Agency for Health Care Administration (AHCA) on the current practices regarding regulating and monitoring Health Maintenance Organizations (HMOs). OIR licenses HMOs after ensuring financial solvency and then continues to monitor their finances periodically. In order to get licensed, HMOs must present a sound business plan, financial statements that reflect solvency, a feasibility study that reflects the potential for success of the business plan, a contingency plan in the event that the business plan can t be fully implemented and a listing of all officers for the organization. Following licensure, OIR continues to monitor the financial health of HMOs through the review of quarterly (monthly if concerns arise) financial statements, audited financial statements, actuarial statements and trends in medical loss and administrative expense ratios. There are currently 40 HMOs operating in Florida, with 18 of them licensed by AHCA to provide Medicaid services. HMO members include 1.1 million Medicaid subscribers and an additional 1.1 million are expected to be added as Florida moves to statewide managed care. The Strike Force then asked staff to gather information from other states on what has been done to address fraud in Medicaid managed care. In addition, staff were asked to work toward promoting greater public awareness among individuals and business owners to emphasize the negative impact that Medicaid and public assistance fraud has on otherwise law abiding citizens. This should be done in the spirit of engaging their assistance in alerting authorities to fraud when they see it occurring. Within AHCA, at least six (6) bureaus are involved in monitoring managed care providers. Monitoring is conducted through annual onsite inspections and contract reviews, as well as quarterly desk audits/reviews. Monitoring efforts look at medical records, reporting of fraud and abuse, complaints and grievances filed, as well as performance measures that profile the health status of enrolled members and provision of services. Quality of services is evaluated based upon coordination of care, utilization management, maintenance of records and administration practices. Contract compliance considers member eligibility, enrollments and disenrollments, services provided, member rights and community outreach. In addition, provider credentialing and recredentialling, provider services, provider contracts and subcontracts and covered services are all reviewed. 12

13 The Problem THE REPORT TO THE LEGISLATURE In 2010, the Legislature found that there is a need to develop and implement a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud, Section (1), Florida Statutes. This finding has been validated by recent trends in utilization that reflect an increasing need for Medicaid and public assistance services. A major driving force behind these trends is the current economic downturn. According to the National Bureau of Economic Research, the current recession began in December of Between December 2007 and December 2011, requests for assistance submitted through ACCESS increased by 28%. SNAP (food stamp) caseloads increased 139% and Temporary Assistance for Needy Families (TANF) caseloads increased by 18%. Although not all as dramatic, other public assistance programs in various state agencies receiving some General Revenue funding report increasing caseloads as well. Along with increases in these caseloads, there has been an increase in referrals to DPAF, as the investigative unit dedicated to fraud detection in these public assistance programs and among Medicaid beneficiaries. Between 2007 and 2011, the number of referrals to DPAF has increased 36.01%. According to Florida s social service estimating conference, between SFY and SFY , Florida Medicaid increased its caseload by 48.7%. By the end of SFY , enrollment reached 3.14 million. As of August 2011, Florida Medicaid was the fourth largest Medicaid program in the country based upon number of recipients. It was also fifth largest in terms of Medicaid expenditures. In July 2012, the estimating conference reported that $20.2 billion had been spent on Medicaid during SFY While there continues to be growth in the Medicaid program and AHCA has implemented efforts to manage costs, AHCA recognizes the continuing need to be persistent about deterrence and detection of fraud and abuse. Health care fraud is a serious and costly problem that affects all Floridians. Although there are varying estimates of the amount of program loss due to fraud and abuse, no one knows for certain how much fraud exists in the Medicaid program. While there are national estimates that range from a low of one percent to a high of 20 percent, these estimates are just that estimates. To be most accurate these figures would actually have to be calculated for each distinct provider type and not the program as a whole. By the time such calculation could be completed on a particular provider type, dynamics within the system and the naturally occurring environment in which it operates would likely result in any findings being dated. A 2010 white paper, Combating Health Care Fraud, published by SAS Institute, Inc. states: Amid these dynamics, fraudsters have become more resourceful than ever. Recruitment and transport of patients for bogus procedures, 13

14 trading narcotics in exchange for member IDs, identity theft, doctor and pharmacy shopping all result in claims that appear legitimate when viewed in isolation. Timely payment requirements, automated claims processing and lack of widespread, prepayment fraud detection capabilities have helped make health care fraud a low-risk, high return criminal activity - second only to tax evasion in economic crime. Today s fraudsters also have a good understanding of fraud detection systems, frequently recruit insiders into their schemes, and actively test and exploit thresholds and detection rules to avoid exposure report (Identity Theft: Trends and Issues) from the Congressional Research Service described the threat that identify theft presents: Identity theft is often committed to facilitate other crimes such as credit card fraud, document fraud or employment fraud, which in turn can affect not only the nation s economy but its security. The report states that although the number of complaints filed and defendants convicted have both declined in the past two years, the number of aggravated identity theft cases have increased. These are just some of the challenges that the Strike Force and partner agencies will face in the next few years. Herein lies a significant challenge to fighting Medicaid fraud: it is the practice of some to test the system, detect new detection tools or enforcement strategies and move their activities to more vulnerable targets within the program. This is exacerbated by the fact that, with the recession, it is becoming easier for sophisticated criminal enterprises to recruit less sophisticated cohorts to assist them - who, in turn, also become victims in the process. This actually points to another vulnerability of a feefor-services system in that the scope of services available is very broad. Florida s current Medicaid enrollment is divided among four broad service delivery systems, which are categorized by the general payment/reimbursement methods used in each. However, within those broad areas, services are broken down into 25 service types, each with different methods used to determine the rates for reimbursement. In partial recognition of this, the 2011 Florida Legislature enacted a requirement that Florida Medicaid transition to statewide managed care. Managed care can be a tool for Medicaid programs to more effectively use resources while improving outcomes. Medicaid managed care organizations are paid a monthly capitation rate and have financial incentives to be vigilant about preventing, identifying and combating fraud and abuse, thus limiting the state s exposure for the risk of fraud. Managed care plans serve as the state s partner in their efforts to fight fraud and abuse, as plans must implement fraud and abuse detection and deterrence activities. Although the plans are obligated to assist in these efforts, it is important for the state to have stringent managed care fraud and abuse prevention and reporting requirements in place through contract and statutory provisions. Managed care plans, though, are not immune to fraud; the risks are just different. One increasing risk that is common to Medicaid and public assistance fraud is identity theft. A February, 14

15 Established Anti-Fraud Resources AHCA. Currently, AHCA has a multitude of processes in place to prevent and detect fraud and recoup overpayments. These are covered in great detail in AHCA s annual report, The State s Efforts to Control Fraud and Abuse, and will not be reiterated here. However, the results of these efforts are important to note. In SFY , overpayments identified by the Bureau of Medicaid Program Integrity (MPI) totaled approximately $36.1 million. In addition, MPI imposed approximately $6.4 million in contractual assessments, fines/sanctions and costs. Identified amounts due AHCA for SFY totaled approximately $42.5 million. In addition to the above, from July 2011 through July 2012, AHCA s MPI accomplished the following: 268 providers were terminated from Medicaid to protect the program; 437 prescribers had their prescribing rights terminated within the Medicaid system to protect against overprescribing, and; 270 providers were placed on pre-payment review. Through the employment of third party liability (TPL) contractors using computer-assisted analyses of paid claims, an additional $148,115,578 was recovered for the State of Florida by AHCA. MFCU. MFCU is the referral point for AHCA when cases are determined to entail fraud, an intentional deception or misrepresentation made by a person with the expectation that the deception results in unauthorized benefit to herself or himself or another person. In SFY , MFCU reported receiving 71 fraud referrals from AHCA. They also report recoveries totaling $161,667, for the year. This represents a 46% increase in recoveries over the prior year. DPAF. As a result of the efforts by DPAF in DFS during SFY , $19,705,985 in public assistance dollars was withheld. Cases involving an additional $3,503,114 were referred back to the Department of Children and Family Services (DCF) for Administrative Hearings and 99.2% of those cases resulted in public assistance disqualification. Cases with an additional $3,883,834 in potential loss due to fraud were referred to State Attorney Offices for prosecution and 96.5% of those cases were accepted for prosecution. This represents an 11% increase in cases accepted for prosecution over the prior year. Database Resources. To assist in their efforts, there exist a number of databases that provide these investigative units with information that assists in their efforts. The descriptions below provide just an initial inventory of what is available and being used. The process of inventorying available databases will be continued by the Strike Force in the next year. The Customer Oriented Medical Practitioner Administration (COMPAS) system is a regulatory system used by the Department of Health (DOH) to track licensure of health care practitioners. The system manages licensure applications, legal sanctions, and consumer complaint information. Although access to information is highly restricted, DOH also maintains the Prescription Drug Monitoring Program (PDMP) system to track the prescription of controlled substance medications that may be abused. The Bureau of Vital Statistics within DOH provides birth and death data to DCF, AHCA and many other state and federal agencies on a daily and weekly basis. Vital Statistics data serves as a resource that agencies can use to help verify identity of clients, verify historical data, and to help prevent potential fraud. The Florida Department of Highway Safety and Motor Vehicles (DHSMV) maintains a unique identifier on all persons licensed to drive in the state. This number is an algorithm that is coded to reflect the driver s first name, last name, middle initial, gender and birth date, followed by a number that represents the number of other people who have the exact same license number. This unique identifier does not change even if the driver changes their name so this can be a valuable tool in guarding against identity theft and fraud. DHSMV also maintains a system called DAVID which is a secure database maintaining driver s licensee information, including pictures. The Florida Crime Information Center (FCIC) database at the Florida Department of Law Enforcement (FDLE) contains Florida conviction, arrest, and warrant information as reported by law enforcement agencies throughout the state and authorized for release to the public. The Comprehensive Case Information System (CCIS) through the Florida Association of Court Clerks and Comptrollers, is a secured single point of search for statewide court case information. This system allows authorized users to search for and receive information from any Florida Court Clerk on filed actions including criminal arrests, dispositions, warrants, and civil cases. AHCA maintains a number of databases to assist in fighting fraud. The Florida Medicaid Management Information System (MMIS) maintains all Medicaid billing and utilization information. The Fraud and Abuse 15

16 Case Tracking System (FACTS) is a case tracking system designed to manage MPI investigations related to fraud and abuse, sanctions, and overpayments. The Medicaid Case Tracking Software application is specifically designed to create the AHCA Office of Inspector General (OIG) Quarterly Statistical Report on demand as well as manage all aspects (even non-reporting related) of active MFCU cases. The Web Document Management (DM) system integrates with AHCA s document management system (Laserfiche) to post documents online for consumers and the public, including provider inspection reports and all legal final orders for sanctions including licensure, Medicaid and any other AHCA legal action. AHCA also maintains a number of financial systems to help track and manage Medicaid activity. The Versa Regulation (VR) system is used to track licensure of health care facilities and providers. The Medicaid Accounts Receivable (MAR) is a FoxPro application used to track Medicaid overpayments due and received by the agency. The Receipts and Accounts Receivable Application (RARA) is an internally developed.net application used to manage accounts receivable and cash receipts for monthly Quality Assessments of Skilled Nursing Facilities and Intermediate Care Facilities for the Developmentally Disabled. The Hospital Accounts Receivable (HAR) system is a FoxPro application used to track non-medicaid payments due and received by AHCA s Bureau of Finance and Accounting. DFS houses several databases for their use in conducting fraud investigations. The Division of Insurance Fraud uses the Augmented Criminal Investigation Support System (ACISS) as their insurance fraud case management system and the Insurance Fraud Plan Reporting (IFPR) system to track anti-fraud plans filed by health care providers and insurance companies. They also use the Insurance Fraud Anti-Fraud Reward Program system to track persons who have filed tips on alleged offenders in the event they become eligible for a reward and the Insurance Fraud Restitution database to track restitution payments from offenders. DPAF maintains the Automated Information Management (AIM) System as a case management system. A number of federal databases are also available for use in Florida s efforts to fight fraud. The ASPEN Central Office (ACO) is the federal system used by AHCA s Health Quality Assurance (HQA) division to manage provider information for federal certification including demographic information, inspections, consumer complaints, and certain federal sanctions. The List of Excluded Individuals/Entities (LEIE) was established by the HHS Office of Inspector General (OIG) to identify persons who should not be licensed to provide Medicaid services based upon convictions for programrelated fraud and patient abuse, licensing board actions, and default on Health Education Assistance Loans. The Fraud Investigation Database (FID) is a comprehensive nationwide system devoted solely to the accumulation of Medicare fraud and abuse data and is currently accessible by the Centers for Medicaid and Medicare Services (CMS) program integrity staff and its contractors, MFCUs, and federal law enforcement agencies. The National Crime Information Center (NCIC) is a computerized index of criminal justice information (i.e. criminal record history information, fugitives, stolen properties, and missing persons). It is available to federal, state, and local law enforcement and other criminal justice agencies. Some agencies can also access LEO Online which is a state-of-the-art Internet system that is accredited and approved by the FBI for sensitive but unclassified information. LEO is used to support investigative operations, send notifications and alerts, and provide an avenue to remotely access other law enforcement and intelligence systems and resources. LEO Online serves as a secure portal for information sharing between federal enforcement entities, the National Insurance Crime Bureau, other state agencies, and AHCA. Multi-Jurisdictional Partnerships. Multi- Jurisdictional Partnerships are becoming increasingly of value in combating fraud. Ten years ago, the U. S. Department of Agriculture (USDA) designated DPAF as the State Law Enforcement Bureau (SLEB) for Electronic Benefit Transfer (EBT) cards. In that role, they serve as the liaison between local and state agencies and USDA in carrying out targeted investigations and prosecution of EBT fraud. DPAF supports the investigations by creating and managing funding of EBT cards that can be used in undercover buys by investigative units. DPAF works with the local law enforcement agencies to ensure that targeted retail establishments are cleared for investigative units to enter under cover and gather the necessary evidence to create a case of fraud against the retail operator. DPAF then collaborates with any involved law enforcement, regulatory and prosecutorial agencies in the pursuit of criminal prosecutions. DPAF also follows up with USDA to provide the information necessary to disqualify the retail locations and with investigations of recipient fraud that may have been integral to the retailer fraud. In the past year, the SLEB has worked actively with over 20 different law enforcement agencies and USDA in an effort to expand upon SLEB operations investigating EBT trafficking in retail stores statewide. In addition, PAF has 16

17 investigated 1,620 SNAP recipients for trafficking their benefits in retail stores in Florida during fiscal year , an increase of 34% over the previous year. Since 2008, the Palm Beach County Sheriff s Office (PBCSO) has been working with the U. S. Department of Housing and Urban Development (HUD) to identify perpetrators of housing fraud and uncover housing fraud schemes in public housing sites in Palm Beach County. The objective of these efforts has been to decrease housing fraud, ensuring that public housing is available to those who are truly needy. The initiative entails identifying individuals who falsify their public housing application. The PBCSO also takes advantage of opportunities to increase awareness among the public that cases will be investigated, perpetrators will be arrested and restitution will be sought. Health Care Fraud Prevention & Enforcement Action Teams (HEAT), are a joint initiative announced in May 2009 between the U. S. Departments of Justice (DOJ) and Health and Human Services (HHS) to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. Since their inception in March 2007, HEAT operations in nine locations have charged more than 1,330 defendants who collectively have falsely billed the Medicare program for more than $4 billion. In these locations, federal agencies join forces with state and local law enforcement to leverage their efforts to fight health care fraud. Florida is home to two of the nine teams across the country. In 2009 a joint investigative team was established in collaboration with the State Attorney s Office for the Fifteenth Judicial Circuit, and HUD s Office of Inspector General (OIG) to investigate criminal activity relating to federal or state funded public assistance. Recently the Sheriff has formally created a PBSO Public Assistance Fraud Unit. This investigative group has expanded to include the Inspectors General for the U.S. Departments of Veteran s Affairs, Agriculture, and the Social Security Administration as well as many public housing authorities and providers. Through the collaboration with these agencies, numerous public assistance fraud investigations are conducted including housing assistance, SNAP (food stamp)/ebt fraud, and other federal and state welfare programs. Through their investigations they have learned that perpetrators of public assistance fraud don t just defraud one program; they typically defraud several simultaneously. When a case comes to their attention that involves an individual who is determined to be receiving public assistance, PBCSO reaches out to other agencies that may be involved with a suspect to determine if they also have an interest in that person as a public assistance beneficiary. As a result of these collaborations to build cases, they have achieved a 100% conviction rate. The most important facet of these collaborations is it has enabled them to find career criminals who are engaged in other illegal activities, such as organized crime or public corruption. In 2011, over 100 public assistance recipients were arrested for fraud and more than $2,000,000 was ordered in restitution by the courts. 17

18 Recent Innovations in Anti-Fraud Initiatives In their first annual report, the Strike Force identified a number of innovative strategies which have continued in the past year. Telephonic Delivery Monitoring and Verification. As a result of anti-fraud and abuse provisions included in Senate Bill 1986 (2009), AHCA contracted with a vendor, Sandata Technologies, to implement the Telephonic Home Health Service Delivery Monitoring and Verification (DMV) Program. This program was designed to address aberrant billing practices, potential fraud and the quality of recipient care in home health care. The contract was signed April 8, 2010, and the DMV project was successfully launched on July 1, As a result of this contract, Medicaid reimbursable home health visits provided by registered nurses (RNs), licensed practical nurses (LPNs) and home health aides are scheduled, verified and tracked through Sandata s payor management system. The goal of the DMV program was to ensure that home health nurses and aides actually visited the homes of recipients who were authorized to receive home health visits and actually provided the services outlined in the recipients plans of care. These assurance measures were deemed necessary to ensure that home health service providers only received reimbursement for services actually provided. Because providers have 12 months from the date of service to submit claims for payments, final numbers are not available, however, the second year of the DMV program is expected to have generated substantial additional savings for Medicaid expenditures in Miami-Dade County. Preliminary statistics indicate that the dollar amount of claims paid in year two of the program was 15% lower than in year one, an estimated additional savings of $3.5M. The second year s savings are in addition to the $19 million cost reduction (a reduction of 46%) achieved in the program s first year. Link Analysis. Link Analysis is a data matching technique used to evaluate relationships (connections) between entities, and has been used in other organizations for the investigation of criminal activity, fraud detection and the development of actionable intelligence. Through link analysis, relationships may be identified among various types of entities or objects, including organizations, people and transactions. In combating Medicaid and public assistance fraud, link analysis is used for three primary purposes: 1) to find matches in data for known patterns of interest; 2) to delineate anomalies where known patterns are violated; and 3) to discover new patterns of interest (through social network analysis and data mining). AHCA. AHCA is currently performing link analyses on individuals and groups found in the following databases: All 130,000 providers in the Florida Medicaid Management Information System (FMMIS) database. All provider owners in the FMMIS database. All provider groups in the FMMIS database. All prescribing doctors in the Medicaid pharmacy system. All providers in the Florida Medicaid managed care networks. All providers in AHCA s Health Quality Assurance (HQA) licensure files. Match and link technologies are being used to gather information from the following sources that may be related to the entities identified above: Federal List of Excluded Individuals and Entities. Other states exclusion lists. DOH adverse actions and previous terminations. Other criminal databases. Florida Corporate records. Medicaid prescribing database. FMMIS ownership records. National Provider Identifier records (National Provider and Plan Enumeration System). Tax records. Property records. Familial and social records. Potential relationships with excluded/criminal entities are identified on the Medicaid providers using different parts of their names, abbreviations, addresses, and other identifying elements. These linking technologies are intended to uncover providers reporting false identity information to evade exclusion matching and to reveal non-disclosed owners, 18

19 directors and officers of companies; violators using their immediate relatives to reopen new companies or continue existing companies often at the same business address; people using their partners to continue doing business or open related businesses; people using multiple electronic funds transfer accounts; and prescribing or referring services (Part D, Labs, and Durable Medical Equipment) in states which either do not require such entities to be enrolled for these referrals or do not check valid referral national provider identifiers (NPI) on claims. DCF. In 2011, DCF worked with LexisNexis in a pilot project using technology to perform link analyses between information available in distinct databases. This pilot project demonstrated the capacity of such link analyses to aid in the verification of applicant identities. Incorporating this technology into the current ACCESS system can prevent identity fraud at the entry point for eligibility determination. MFCU Data Mining. One challenge MFCU faced in the past was getting access to Medicaid claims data to generate leads for investigations. MFCU operates on a budget that includes federal matching grant funds and one federal grant restriction did not allow MFCU to engage in data mining. Data mining refers to the practice of electronically sorting Medicaid Management Information Systems (MMIS) claims through statistical models and intelligent technologies to uncover patterns and relationships contained within the Medicaid claims activity and history to identify aberrant utilization and billing practices that are potentially fraudulent. The rationale for this restriction was that AHCA was already receiving federal funds to do this data mining and the federal government didn t want to pay two agencies to do the same thing, since it had historically been a costly process. Since the initial enactment of the restriction, however, processes have become more automated and there have been huge advances in computer hardware, software and the ability to manage data. In addition, MFCUs have developed the capability to undertake such tasks. However, the federal grant restriction has remained in place. Although they have not yet been adopted, the U.S. Department of Health and Human Services (HHS) proposed amendments to the Federal Code in 2011 to allow more flexibility for MFCUs to do data mining. The Florida MFCU, in collaboration with AHCA, asked the Centers for Medicare and Medicaid Services (CMS) for a waiver of the grant restriction. The objective was to supplement AHCA s data mining activities. CMS granted the waiver request as a three year pilot project that began October 1, Florida is the only state that has been granted such a waiver. For the first year of the project, three Medicaid Fraud Analysts devoted up to 15 percent of their time to the project. During the last two years they will devote up to 25 percent. As of June 30, 2012, the MFCU had submitted 63 data mining projects to AHCA for review and 59 were approved. They had also opened 36 cases and 13 complaints from these projects for which they are currently developing targets. MFCU s Complex Civil Enforcement Bureau. The Complex Civil Enforcement Bureau (CCEB) is a section within MFCU. CCEB investigates and litigates cases that allege violations of the Florida False Claims Act when the false claims were submitted to the Florida Medicaid program. The majority of the cases are qui tam actions filed in federal court containing allegations that the Florida False Claims Act has been violated. CCEB evaluates qui tam complaints and prioritizes them according to their underlying merit and value to the State of Florida. In addition, CCEB has expanded the Florida MFCU s role among the multi-state working groups litigating Medicaid fraud issues. MFCU False Claims cases resulted in recoveries of $145,374, in SFY DCF s Office of Public Benefits Integrity. The Office of Public Benefits Integrity (PBI) was established in January 2011 to enhance DCF s efforts to prevent, detect and recover funds lost to public assistance and Medicaid fraud. Among other efforts, existing technology has been optimized to better detect fraud risk factors, such as identity theft. In one example, the identities of individuals currently incarcerated were being used to receive public assistance benefits. The results to date have been tangible, with the dollar value of fraud prevented increasing by 10 percent since the beginning of 2011, while recoveries have increased by 16 percent over last year. Process Mapping. As used here, process mapping is another term for business process mapping. Business process mapping refers to activities involved in defining exactly what a business entity does, who is responsible, to what standard a process should be completed and how the success of a business process can be determined. Once this is done, there can be no uncertainty as to the requirements of every internal business process. The first step in gaining control over an organization s performance is to know and understand the basic processes. 19

20 Emergency Suspension Order (ESO) Expedition. One example of the benefits that can be gained through Process Mapping dealt with Emergency Suspension Orders at DOH. In May 2011, the Division of Medical Quality Assurance (MQA) in DOH streamlined the process to take emergency actions against licensed health care practitioners who pose an immediate threat in order to take more timely emergency actions to reduce the threat to the health, safety and welfare of the public. A root cause analysis revealed that threats to the public health, safety and welfare had changed over the last few years, requiring redefining what constituted a priority investigation. In addition to several other improvements, a unit was created in the Prosecution Services Unit specifically for handling emergency actions. In SFY , emergency actions were issued in an average of 106 days. As a result of the process improvements, an aggressive target was set to issue emergency actions in less than 30 days from receipt of a priority complaint beginning July 1, 2011 and removing or restricting licensed individuals who are not safe to practice. For fiscal year , a total of 376 emergency actions were issued in an average of 74 days with 41% issued within 30 days. The number of emergency actions issued increased 16% from fiscal year HHS OIG Medi-Medi Project. The Medi-Medi project provided funding to state Medicaid agencies to collaborate with a number of federal agencies in analyzing billing trends, particularly among dual (Medicare and Medicaid) enrollees to identify potential fraud, waste, and abuse. The Medicaid agency looks at dual enrollees on a regular basis to detect instances of duplicate billing and then refer suspected fraud to the MFCU or to HHS Office of Inspector General (OIG), as appropriate. The Medi-Medi program produced limited results and few fraud referrals. During 2007 and 2008, the program - in which 10 States had chosen to participate - received $60 million in appropriations and it avoided and recouped $57.8 million. The program produced 66 referrals to law enforcement, and law enforcement accepted 27 of these. Among all 10 participating States, each State averaged 2.8 Medicare referrals to law enforcement per year; law enforcement accepted an average of 1.15 referrals per State per year. In comparison, each State averaged 0.5 Medicaid referrals to law enforcement per year; law enforcement accepted an average of 0.2 referrals per State per year. Also, State Medicaid programs received less benefit from the Medi-Medi program than Medicare received. Of the $46.2 million total in Medicare and Medicaid expenditures recouped through the program during 2007 and 2008, more than three quarters ($34.9 million) was recouped for Medicare. 20

21 New and Innovative Local, State and Federal Initiatives AHCA Assisted Living Facility (ALF) Forms. This initiative was launched in August, 2011 to make state agencies, and those contracted with state agencies, aware of improper conditions (i.e., indications that residents are not receiving appropriate medical care) at Assisted Living Facilities of which AHCA should be notified. At that time, the agency compiled a one-page list of specific instances in which they should be contacted to properly review the conditions observed at the assisted living facility. This list and reporting instructions can be found at myflorida.com/mchq/long_term_care/assisted_ living/alf/alf_observations_list.pdf AHCA followed up with training via Web X on March 19, 2012; March 22, 2012; April 9, 2012; and April 12, 2012, for various state agencies and personnel contracted with the agency. The goal is to ensure that all ALF residents receive appropriate healthcare. Facilities that provide substandard care as well as facilities providing care that exceeds the scope of the staff or the facility s licensure increase the cost of healthcare for Medicaid recipients. The overall outcome expected is to decrease the cost of Medicaid throughout the entire continuum of care, including otherwise unnecessary hospital admissions or rehabilitative services required due to inappropriate care ALF Site Visits. Between December 2011 and March 2012, AHCA staff reviewed 92 assistive care services providers in Broward, Palm Beach and St. Lucie Counties. Compliance site visits were conducted in facilities billing for a specific procedure code used for Personal Care Service at Per Diem rate (T1020) for dates of service from January 1, 2011, to November 30, The agency also conducted compliance site visits to 100 ALFs in Miami-Dade County. These ALFs billed for procedure code T1020 for dates of service from January 1, 2011, to February 29, These site visits were conducted to: Determine if Assistive Care Services providers were rendering, billing and documenting the provision of services in accordance with Medicaid policy Verify the ancillary services received by residents of Assistive Care Services facilities; Check for duplication of services such as home health and waiver services; Determine if Assistive Care Services were rendered by qualified and properly trained staff as required by Chapter 429, Florida Statutes, and the training requirements of Chapter 58A (1), Florida Administrative Code (F.A.C.); and Identify quality of care and environmental issues. The outcomes from these efforts were significant. In Broward County, the actions taken included 76 Sanctions (totaling $461, in fines), 10 Paid Claim Reversals (valued at $64,443.03), 32 Prepayment Reviews, 1 DOH referral, 1 Health Insurance Portability and Accountability Act (HIPAA) compliance referral and 1 Medicaid contract termination. In Miami-Dade County, actions taken included 80 Sanctions (totaling $389, in fines), 13 Paid Claim Reversals (valued at $69,979.04), 24 Prepayment Reviews, 2 DOH Referrals, 2 Medicaid contract termination recommendations and 1 MFCU Patient Abuse, Neglect and Exploitation (PANE) referral. Background Screening. Electronic fingerprinting for Medicaid criminal background screening was established based on 2010 Florida legislative changes. Recent 2012 legislation, Chapter , Laws of Florida, established requirements for submission of retained prints. Retained prints enhance anti-fraud efforts by providing notification to AHCA upon the arrest of an individual who has been previously screened for Medicaid or employment. In addition, this legislation authorized the creation of a secure, web-based Care Provider Background Screening Clearinghouse at AHCA to house and manage screening results of health and human service agencies including the Agency for Persons with Disabilities (APD), Department of Elder Affairs (DOEA), DCF, DOH, the Department of Juvenile Justice (DJJ) and the Department of Education s Division of Vocational Rehabilitation (DVR). The Care Provider Background Screening Clearinghouse created the infrastructure for sharing screening results across these agencies. Retained prints will be implemented for these programs as they participate in the clearinghouse. AHCA recently requested an extension of a federal background screening grant to complete the Care Provider Background Screening Clearinghouse. The agency anticipates adding DVR to the clearinghouse by January 2013, with the other agencies to follow by October Case Management System Replacement. The 2011 Florida Legislature approved a Legislative Budget Request in the amount of $800,000 to enable AHCA to replace its legacy case tracking system and incorporate advanced 21

22 detection capabilities. An Invitation to Negotiate was released in May 2012 inviting vendors to propose services to replace the legacy Medicaid Program Integrity case management system. Vendors were asked to propose a system that would improve Medicaid Program Integrity s productivity by streamlining and automating many of their processes and improve the ability to manage cases. Vendors were also asked to provide features that would improve fraud and abuse detection capabilities through the entire lifecycle of a case from alert/complaint triage to audit package creation, audit plan development, procedure and expectation management, claim research and analysis, field investigation, sampling, medical review, overpayment determination, audit reporting and recovery tracking. The qualified responses were evaluated and negotiations with the vendors were held in July A contract is anticipated to be signed and implemented by early The outcomes will include increased identification of Medicaid overpayments, fraud and abuse and more efficient audit and recovery operations undertaken by AHCA s MPI. Data Connectivity Plan Update. In December 2010, AHCA developed a Strategic Plan for Data Connectivity of Health Care Fraud Databases. This working strategic plan provided goals and objectives aligned with the strategic priorities provided in Section (38)(b), Florida Statutes. These priorities serve as drivers for combating fraud and abuse in the Florida Medicaid program by addressing detection and prevention activities, as well as methods to recover improper payments to Medicaid providers. AHCA designed the plan to be a dynamic document that can be adjusted to meet the needs of an ever-changing Medicaid service system. During the past fiscal year, the agency revised the Strategic Plan to document new databases that were identified that could assist in the fight against health care fraud and abuse, as well as to identify new opportunities to connect databases storing health care fraud related information. The revised Strategic Plan was issued on March 7, Continuously refining this Strategic Plan provides AHCA with a roadmap to ensure that all relevant information is available to assist the agency in its fight against health care fraud and abuse. The plan provides for replacing AHCA s current case tracking system employed by MPI with a replacement system that incorporates advanced detection methodologies, as described above. Data Mining. AHCA is adding a new tool to their existing set of detection tools predictive modeling software. This new technology/software will identify data anomalies not found using traditional detection tools and allow the detection of outlier providers based on aberrant aggregate utilization compared to peer providers. This new software-based approach is an enhanced capability because it facilitates fraud detection in Medicaid claims by evaluating every claim in the context of another claim to determine the probability of whether the claimed encounter actually took place, and if so, evaluating whether the claim was accurately represented. This solution will also utilize a relativistic 360-degree view of claim components (provider, beneficiary, procedure code, diagnosis code) across claims and non-claims data, enabling detection scenarios that are richer and more dynamic than siloed analyses performed on each claim type. This new tool is scheduled for implementation in the fall of 2012 and is expected to enhance detection capabilities, improve recovery efforts, produce a higher return on investment and increase more appropriate referrals to the MFCU and law enforcement. Group Home Site Visits. In September 2011 AHCA conducted compliance site visits to 52 Developmentally Disabled (DD) Waiver-Residential Habilitation Service providers (group homes) in Miami-Dade, Broward and Palm Beach Counties. These group homes were high billers of Residential Habilitation (procedure code T2023U6) for dates of service between January 1, 2011 to September 25, These visits were conducted to: Determine if residential habilitation service providers (group homes) rendered services in accordance with Medicaid policy; Determine if residential habilitation services were rendered by qualified and properly trained direct care staff; and Identify deficient quality of care and environmental issues for correction Actions taken as a result of these site visits included 19 Sanctions (totaling $87,000 in fines), 14 Agency for Persons with Disabilities (APD) Referrals, 5 Prepayment Reviews, 1 MFCU/PANE Referral, 1 DOH Referral, 1 Social Security Administration /Office of Inspector General Referral and 2 Provider Education Letters. Health Care Clinic Regulations. AHCA s Division of Health Quality Assurance (HQA), the licensing division, and AHCA s Division of Medicaid are exploring new data mining strategies. The strategies being explored will require that they overcome database differences by creating a crosswalk between AHCA s HQA/Health Care Clinic databases and Medicaid provider enrollment to identify those facilities requiring either a health care clinic 22

23 license or a certificate of exemption from licensing. The Medicaid/HQA Medicaid Waiver crosswalk has already been created, but has not yet been tested. This initiative s test is expected to be completed by the spring of Once the crosswalk is completed and tested the initiative will occur in three phases: Phase I is to data-mine the licensing and provider enrollment database to identify health care facilities that either have or do not have required licensing or exemptions. Phase II is to do a test run with a single provider type to require licenses or exemptions within a period of time. Phase III is to fully integrate health care clinic licensing and exemptions for all Medicaid enrolled and non-enrolled providers. The initiative is intended to require and enforce state licensing and exemption requirements for health care clinics as a condition of Medicaid program enrollment to ensure that only licensed or appropriately exempt providers bill the Medicaid program. Health Care Clinic Site Visits. Between November 28, 2011 and December 12, 2011, AHCA reviewed 63 licensed health care clinics in South Florida in order to verify that the clinics had a physical location and were in compliance with AHCA licensure requirements. Based on these reviews, the agency found that 14 of the 63 clinics were closed or had relocated without notifying AHCA. All of the clinics focused on treating auto accident patients and were reimbursed through personal injury protection (PIP) billing. Of the 49 clinics found to be open for business, only 14 patients were observed during the 49 visits. A large number of clinics posted advertisements for law firms focused on auto accident litigation. A large number of clinic owners were not aware of the content of the financial viability statements prepared and submitted on their behalf by their certified public accountants. As a result of this initiative, the AHCA Office of Inspector General (OIG) referred 36 clinics to HQA for regulatory violations. To date, two referred clinics have closed, one license was revoked, one sanction of $500 was imposed, and one clinic has pending disciplinary action. Twentyfour clinics referred to HQA rapidly completed and submitted the required Level 2 background screenings. Non-Enrolled Prescription Provider Suspensions. Beginning in October 2011, AHCA started to review all health care practitioners that were prescribing pain pill drugs purchased by the Medicaid program in order to preclude Medicaid from paying for unnecessary or abusive prescriptions. Providers identified as having high prescription rates and who were not actively enrolled in the Medicaid program were recommended for suspension from the Pharmacy Benefits Management Program pursuant to Section (8) Florida Statutes. (Suspension in this program means that Medicaid will not pay for prescriptions written by the prescriber.). Since October 2011, 395 non-medicaid-enrolled pain pill prescribers have been suspended from prescribing drugs to Medicaid recipients. At the time of this writing, the cost avoidance figure has not been calculated, however it should be available by October 1, Pain Pill Doctor Suspensions. In February 2012, AHCA began to routinely identify outliers in high pain pill prescribing and review the top Medicaid pain pill prescribers for potential suspension from the Medicaid program or referral to MFCU. This initiative was launched to enhance the identification of provider over-utilization, increase recoveries of Medicaid funds for prescribing without proper documentation in the medical records, and continue to refer suspected pill mill prescribers to other appropriate regulatory agencies and law enforcement. Recently, this review led to the immediate termination of a prescriber who was responsible for dispensing 1,973,577 pill mill type drugs. AHCA is also currently looking at a new audit and recoupment process that will focus on medical records review and pain pill prescribing. Under this new process, if an audited provider cannot support the prescription(s) with appropriate Medical records documentation, the agency will request Medicaid reimbursement from the physician that wrote the prescription and consider other actions such as suspension from prescribing to Medicaid recipients and referral to other state and law enforcement agencies. Public Assistance Reporting Information System (PARIS) Matches. Starting in August 2011, AHCA began using the Public Assistance Reporting Information System (PARIS) to conduct computer matching to identify public assistance recipients who may be receiving concurrent or duplicative services from other states or the federal government. PARIS is a national information exchange system that provides states with a list of beneficiaries that indicates potentially duplicative service recipients. This particular initiative matches the PARIS results with Florida Medicaid claims and recipient demographic data to detect fraud, depopulate recipients actively enrolled in other states programs or eligible for Veterans benefits, identify any potential recovery or termination actions, and ultimately achieve cost savings in Florida s Medicaid and entitlement programs. 23

24 AHCA anticipates cost savings for the Medicaid program and other entitlement programs as a result of this initiative. Recipients who have moved from Florida and enrolled in another state s Medicaid program can be identified more expediently and removed from Florida s Medicaid rolls. Additionally, Medicaid recipients who are covered by the Federal Tri-Care insurance program and are currently enrolled in a Medicaid managed care plan will be unenrolled and placed in the Medicaid fee-forservice program. In addition, the matches will identify Veterans who are eligible for Veterans Administration (VA) healthcare coverage so the agency can work with the Department of Veterans Affairs to facilitate the enrollment of eligible parties into VA programs (such as VA long term care programs). DBPR Drug Devices and Cosmetics Controlled Substance Reporting System. The 2011 Florida Legislature adopted a number of statutory changes to ensure reporting of and better tracking of the distribution of controlled substances. Section (14), Florida Statutes, requires each prescription drug wholesale distributor, out-of-state prescription drug wholesale distributor, retail pharmacy drug wholesale distributor, manufacturer, or repackager that engages in the wholesale distribution of controlled substances as defined in Section , Florida Statutes, to submit a monthly electronic report to the Department of Business and Professional Regulations of its receipts and distributions of controlled substances listed in Schedule II, Schedule III, Schedule IV, or Schedule V as provided in Section , Florida Statutes. Wholesale distributor facilities located within this state must report all transactions involving controlled substances and wholesale distributor facilities located outside this state must report all distributions to entities located in this state. Having this system in place will help identify aberrant distributions and receipts of controlled substances which could reflect potential abusive or fraudulent prescriptive practices. DCF Excessive EBT Card Replacement Monitoring. Repeated requests for EBT card replacements can be a sign of fraud. Beginning in August 2012, another effort to reduce EBT trafficking was launched by DCF s PBI. DCF adopted a policy to inform customers who replace their cards more than three times in a twelve month period that they have been placed on a watch list. These recipients will be monitored and reviewed at scheduled intervals. Online Identity Verification Initiative. DCF is currently developing an automated process which will verify and authenticate an applicant s identity during the public benefits online application process. This technology will protect the misuse of applicant s personal information (identity theft); enhance the prevention of fraud, waste and abuse; and reduce the amount of manual effort required to verify identity. This initiative is scheduled to launch in January Online Monitoring of Social Media. Beginning in March 2012, in an effort to reduce EBT trafficking, the Office of Public Benefits Integrity (PBI) started monitoring social media sites, such as Craigslist, to identify individuals attempting to sell their EBT Card. PBI staff contact the person who posted the information and inform them of the seriousness of their actions and the penalties associated with trafficking public assistance benefits. Procurement of New EBT Vendor. In an effort to reduce fraud, waste and abuse in the Temporary Assistance for Needy Families (TANF); Women, Infants and Children (WIC); and Supplemental Nutrition Assistance (SNAP) programs, DCF initiated the process of securing a new vendor for the EBT system in May The new EBT system will incorporate the latest technology available to combat fraud in these programs. Included in the EBT procurement were several fraud prevention/detection capabilities including predictive analytics and enhanced monitoring reports. The incorporation of real-time alerts to assist DFS DPAF in investigating retailers suspected of trafficking EBT benefits is being explored with the vendor. The contract with the new EBT vendor is scheduled to go into effect July 1, DFS State Law Enforcement Bureau (SLEB) Operation Expansion. In an effort to expand law enforcement activities to address fraud in the USDA SNAP program, the DFS DPAF held a conference in September 2012 to increase awareness of what the SLEB does and how they collaborate and coordinate with federal and local law enforcement agencies to combat trafficking in the SNAP program. The conference was attended by about 100 people from around the state and the country and over half of them were from local law enforcement agencies in Florida. There were also a number of Florida regulatory agencies represented. Conference sessions focused on encouraging participants to become SLEB partners by entering into an agreement to coordinate with the SLEB in conducting investigations 24

25 and follow program requirements as designated by USDA. Sessions covered the procedures for getting clearance to conduct an operation at a particular retail establishment as well as the diverse other criminal activities that may be uncovered during the operation. This was a particular high point of the conference because it clarified how working as a SLEB partner could actually work to the advantage of local law enforcement that may have suspicions about other activity at the retailer. DOH Licensure Actions for Section , Florida Statutes, Fraud Convictions. In an effort to reduce health care fraud in Florida, the Florida Legislature enacted laws to prohibit individuals who commit health care fraud from obtaining a license as a health care practitioner in Florida and to deny licensure renewal to health care practitioners who commit health care fraud. In 2009, SB1986 was passed to go into effect July 1, This law required that DOH deny licensure or renewal for practitioners with felony convictions and/or Medicare/ Medicaid terminations for cause. The 2012 Florida Legislature followed that with the passage of HB 653, effective July 1, 2012, which further prohibited licensing or renewing the license of individuals with certain felony convictions related to health care fraud. This will increase the number of licensees who may be subject to license denial/non-renewal. Prescription Drug Monitoring Program (PDMP). The Electronic-Florida Online Reporting of Controlled Substances Evaluation program (E-FORCSE ) is the name of Florida s Prescription Drug Monitoring Program (PDMP). E-FORCSE was created by the 2009 Florida Legislature in an initiative to encourage safer prescribing of controlled substances and reduce drug abuse and diversion within the State of Florida. The purpose of E-FORCSE, which became active September 1, 2011, is to provide information that can help guide a health care practitioner s prescribing and dispensing decisions regarding highly abused prescription drugs. Through this initiative, DOH is working to: Reduce the rate of inappropriate use of prescription drugs through department education and safety efforts. Reduce the quantity of pharmaceutical controlled substances obtained by individuals attempting to engage in fraud and deceit. Increase coordination among partners participating in the prescription drug monitoring program. Involve stakeholders in achieving improved patient health care and safety and reduce prescription drug abuse and prescription drug diversion. FDLE Regional Drug Enforcement Strike Forces. In spring of 2011, FDLE provided $828,059 in Justice Assistance Grant/Byrne Memorial Law Enforcement Grant funds to establish seven Regional Drug Enforcement Strike Forces (RDESF) to pursue investigation and prosecution of illegal prescription drug operations (pill mills). The RDESFs were organized in March 2011, and grant funds were awarded in April The RDESF efforts included multi-disciplinary investigations of doctors and pain clinics that were criminally and/or administratively violating the letter and/ or spirit of Florida s Medicaid laws and regulations. The goals of the RDESFs are to identify, investigate, and apprehend medical doctors and close clinics and pharmacies fraudulently prescribing and dispensing powerful narcotics. The grant funds were used for a variety of activities, including officer overtime, controlled buys, expert witness fees, training, and purchase of investigative equipment, some of which were directly targeted at fraud in Florida s Medicaid and public assistance programs. As of mid-august 2012, RDESF efforts statewide have resulted in the arrest of 3,173 individuals (including 52 doctors), the closure of 254 clinics, and the seizure of 750,303 pharmaceutical pills, 93 vehicles, 494 weapons, and $9,780,548. MDPD Local Law Enforcement Operations. The Miami- Dade Police Department (MDPD) detectives currently conduct investigations into reports of suspected pill mills and fraudulent prescriptions that are presented to pharmacies. Their pill mill investigations have been conducted throughout the years and are intended to identify and arrest individuals involved in illegally prescribing controlled substances. The prescription fraud investigations were first initiated in October 2011 and target individuals illegally obtaining controlled substances. Strike Force Initiatives Fraud Rate Project in SNAP. In August 2011, an Economist was hired to determine the fraud rate within SNAP in Florida and the Strike Force coordinated with DCF to select a random sample of payments made to program beneficiaries within a three month period of 25

26 time. Using this sample of payments, the Consultant worked with DFS DPAF and DCF s PBI to review the beneficiaries eligibility status at the time the payment was issued. Although this project has been delayed due to staff turnovers within PBI, it is anticipated that this project will be complete prior to the next Strike Force meeting and the results reported at that time. The results can then be used to establish a baseline for beneficiary fraud within SNAP and allow for an evaluation of the impact of the many innovations currently being implemented or planned by DCF. investigation and recoupment of funds processes across the agencies that are primarily responsible for combating fraud in the Medicaid and public assistance service systems. The Strike Force worked with AHCA to utilize the prevention, detection, recoupment process maps developed as a result of Senate Bill 1986 (2009 Legislative Session). AHCA s process maps, while focused on provider fraud, are ones that can be replicated for recipient and public assistance business practices. The resulting high level overview is shown here and more detailed descriptions of each of the circles depicted are presented on the following three pages. Intergovernmental Coordination and Communication. Based upon a finding that there is a need to develop and implement a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud, (Section (1), Florida Statutes), one important role for the Strike Force to serve is to facilitate Intergovernmental Coordination and Collaboration. Responses to a survey conducted in June 2012 among the Strike Force members indicated that this is a role that is being fulfilled. The following were included among the most important/significant accomplishments of the Strike Force since it first organized in February 2011: a. Enhancing the communications between the Medicaid fraud and abuse programs and the other public assistance fraud and abuse programs. b. Coordination of efforts between multi state agencies. c. Increased information sharing among agencies and law enforcement entities tasked with rooting out public assistance and Medicaid fraud in Florida. d. Fostering and promoting inter-agency cooperation and sharing of ideas to prevent, detect, and counter public assistance fraud. One comment stated, the Strike Force approach facilitates use of all the tools available to each agency in a coordinated and cohesive manner to maximize results. In fact, continued Interagency Coordination and Communication was ranked as the number three priority for the Strike Force to pursue in the coming year. Process Mapping. With input from the Strike Force state agency representatives and the assistance of a consultant, the Mapping Committee completed a high level representation of the prevention, detection, 26

27 INTER-AGENCY ANTI-FRAUD & ABUSE PROCESS FRAMEWORK Screening Oversight & Controls Education PREVENTION Application & Payment Reviews Claim Adjustments Monitoring & Regulation Collections Sanctioning Case Mgmt. & Investigations Data Mining & Detection RECOVERY Litigation & Prosecution Recipients Providers Employees DETECTION Site Visits, Surveys & Audits This first picture reflects the general areas that were considered in order to create a high level overview of the antifraud processes across all of the agencies that are involved in the Medicaid and public assistance fraud service delivery systems. At the earliest point in the process (top circle), the efforts focus on prevention and include activities that would generally be categorized as Screening, Education, Application & Payment Reviews and Oversight & Controls processes. These are processes that take place before a payment is ever issued to a beneficiary or provider. The processes in the next circle to the right target the detection of fraud after a payment has been made. These activities are generally categorized as Monitoring & Regulation; Data Mining & Detection; Site Visits, Surveys & Audits; and Case Management & Investigations. The last circle (bottom left) focuses on the processes to recover funds and other resources lost as a result of fraud and/or abuse. These general activity categories include Claim Adjustments, Sanctioning, Litigation & Prosecution, and Collections. The triangle at the bottom of the figure on this page indicates that there are three populations that must be monitored by these activities: Recipients (or beneficiaries of services), Providers, and Employees of the agencies that administer the programs. 27

28 KEY AGENCY FRAUD & ABUSE PREVENTION PROCESSES 1 - Healthcare professional licensure. (DOH MQA) 9 - Integrity oversight, prevention controls, & self-assessments targeting providers. (AHCA IG) 2 - Background screening and ed. for providers dealing primarily with the disabled. (APD) 8 - Provider claim edits, pre-payment reviews, and other reviews. (AHCA, MS, MCM, & MPI) PREVENTION 3 - Facility licensure and site visits for federal certification as a Medicaid provider. (AHCA HQA) 7 - APD recipient eligibility determination screening. (APD) 6 - Recipient eligibilty determination screening. (DCF ACCESS) 4 - Approval of managed care provider health plans/contracts. (AHCA HQA & HSD) 5 - Medicaid policy dev., enrollments, and provider ed. (AHCA Dir.s Office, MCM & Area Offices) Legend AHCA DCF DOH APD OAG/MFCU DFS/PAF Processes to avoid fraud and/or abuse prior to payments This circle and the next two depict the various processes employed by the different stakeholder agencies (color-coded to match the agency engaging in that process) in Prevention (above), Detection and Recoupment (next two pages) 28

29 KEY AGENCY FRAUD & ABUSE DETECTION PROCESSES 1 - Provider site visits and audits. (AHCA MHC, HSD, HQA, MPA, MPI & MQM 13 - Medical provider fraud investigations. (OAG/MFCU) 2 - Monitoring, inspections and regulation of health care professionals. (DOH MQA) 12 - Internal and external provider fraud investigations. (APD IG) 11 - Case management and internal/external fraud investigations of providers. (AHCA IG & MPI) 10 - Recipient fraud investigations. (DFS/PAF) DETECTION 3 - Group home licensure. (APD) 4 - Monitoring and regulation of providers dealing with disabled. (APD) 5 - Provider data mining and detection. (AHCA MQM, MPI & TPL Vendor) (OAG/MFCU) (APD) 6 - Provider data mining and detection. (APD) 9 - Recipient eligibility verification investigations. (DCF ACCESS Integrity) 7 - Home visits and audits of providers and facilitators. (AHCA) 8 - Home visits and audits of providers. (APD) Legend AHCA DCF DOH APD OAG/MFCU DFS/PAF Processes to monitor, detect, or investigate fraud after an instance of fraud and/or abuse has occured 29

30 KEY AGENCY FRAUD & ABUSE RECOVERY PROCESSES 1 - Provider claim adjustments. (AHCA Medicaid Area Field Offices) 11 - Criminal prosecutions. (OAG Statewide Prosecutor) (USDAs & Florida SAs) 2 - Medicaid provider self-audits. (AHCA) 10 - Recipient collections. (DCF Benefit Recovery) 3 - Monitoring and regulation of providers dealing with disabled. (APD) 9 - Provider collections. (APD Field Offices) RECOVERY 8 - Provider collections. (AHCA Finance and Accounting) (DOH support) 4 - Provider sanctioning. (AHCA Director s Office and MPI) 7 - Litigation and settlements. (OAG/MFCU) 5 - Litigation and support. (AHCA General Counsel s Office & TPL Vendor) 6 - Recipient sanctions. (DCF IG) Legend AHCA DCF DOH APD OAG/MFCU DFS/PAF Processes to recover funds and other resources lost as a result of fraud and/or abuse 30

31 As a result of this project, the Mapping Committee identified the ACCESS system (for public assistance benefit applications) as the next targeted process area to be mapped. It was selected by the Committee because, as the entry point for any person applying for Medicaid or public assistance, it was considered to be a most vulnerable area. This mapping is currently underway. Review of Potential Fraud in Managed Care. In the past year, Strike Force staff conducted a review of the fraud risks inherent in moving to statewide managed care. Though the managed care providers will assume the risks in a number of areas, Table I. on the next page provides a list of where the risks may arise that must be addressed in a statewide managed care program. Targeted Local Operations. Having recognized the successes of similar initiatives, as described in this report, the Strike Force is partnering with the DFS DPAF to promote Targeted Local Operations Partnerships. As the SLEB for USDA, DPAF can provide technical assistance on the mechanics to promote Targeted Local Operations Partnerships and the Strike Force membership can promote the concept. more cost-efficiently. The Strike Force is seeking technology and related services solutions that can: Reduce improper payments; Improve administrative efficiency; Detect fraud, waste and abuse; Increase overpayment recoveries; and Generate overall cost-savings to the State of Florida. Responses to this RFI, due in early November 2012, will be used to develop a reference inventory of available technology and other anti-fraud solutions for access by the Strike Force partnering agencies in their future efforts to explore solutions. The utilization of such a database may prove useful in coordinating future Information Technology projects and procurements or making decisions as to the best use of resources in acquiring the most effective and current technology available. Edward Byrne Memorial Justice Assistance Grant (JAG) Program. FDLE serves as the State Administering Agency for the Edward Byrne Memorial Justice Assistance Grant ( JAG) Program. This program is the primary provider of federal criminal justice funding to state and local jurisdictions and can be used to support a range of program areas including law enforcement; prosecution and court programs; prevention and education programs; corrections and community corrections; drug treatment and enforcement; crime victim and witness initiatives; and planning, evaluation, and technology improvement programs. Local units of government can ask to use their allocated funds to implement anti-fraud initiatives, within certain programmatic restrictions. As the Strike Force launches promotions of Targeted Local Operations Partnerships, staff will remind local law enforcement agencies that this is a potential funding source and refer them to FDLE for more information. Technology/Solutions RFI. With direction from the Strike Force Technology Committee, a Request for Information (RFI) was drafted and issued to collect information, options and solutions associated with technologies and related services that can be used to prevent or detect fraud, waste and abuse in Medicaid and public assistance programs and/or recover overpayments 31

32 Table I. 1 POTENTIAL FRAUD RISKS OF MANAGED CARE ORGANIZATIONS 1 Withholding or unreasonably delaying payments to subcontractors, providers or provider groups; 2 Destruction of claims and documentation; 3 Embezzlement of capitated funds paid by the state; 4 Theft of funds, equipment and services; 5 Fraudulent subcontracts (e.g., where no services are provided or false management contracts) 6 Fraudulent related-party transactions; 7 Excessive salaries and fees to owners or associates; 8 Bust-outs (State funds go in, no money goes out to vendors, then bankruptcy or owner flees); 9 Collusive bid-rigging (between plans and may involve collusion with state employees); 10 Improper enrollment practices (attracting good risks or refusing bad risks as members); 11 Improper disenrollment practices (eliminating bad risks by forcing sicker patients to leave); 12 Disenrolling patients prior to hospital treatment, then reenrolling them after recovery (so that the hospital stay is covered by fee-for-service state programs); 13 Conversely, creating program obstacles to prevent dissatisfied members from disenrolling; 14 Falsification of new enrollees (phony patients or phony enrollments); 15 Kickbacks for primary care doctors for referrals of sicker patients to out-of-network specialists; 16 Arbitrarily excluding certain patient groups (e.g., mentally ill, infants, elderly, etc.) from coverage; 17 Regularly denying treatment requests without regard to proper medical evaluation; 18 Creating policies that require an appeal before treatment will be approved and paid; 19 Measuring performance only in terms of absence of specific breaches of existing contract; 20 Failing to notify assigned members of their rights, yet keeping state capitation payments; 21 Failing to procure health providers so that no services are actually provided to members; 22 Retaining excessive administrative fees, leaving inadequate funds for services; and 23 Assigning excessively high numbers of patients to service providers, making adequate services impossible. 32

33 Needs Assessment and Recommendations As part of its mission, the Strike Force has continued its efforts to gather information through meetings of the Strike Force and its committees. In June 2012, a survey of Strike Force members was conducted to identify needs to be addressed or additional improvements that can be made in the Florida Medicaid and public assistance delivery systems. The survey requested input on activities that Strike Force staff had proposed for the next year, other areas of need that the members were aware of and a prioritization of strategies to be supported by the Strike Force. The following needs were identified as areas to address in order to develop and implement a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud, Section (1), Florida Statutes. These are listed by general activity area in priority order, as ranked by the Strike Force members. However, the recommendations under each priority area are listed in no particular order. Those requiring legislative action are noted as such. Priority Activity Area 1: Secure Adequate Funding A recurring theme in reports to the Strike Force is the lack of resources available to support existing processes intended to prevent, detect, investigate and prosecute fraud. From the need for additional staff, to more competitive salaries, to better training, no agency is funded at the level they would prefer. Some of these needs can be met in part through better, more advanced technology. However, this will require an investment in resources, as well. There are certainly indications that there are already significant returns on investment being achieved. AHCA dedicates a significant amount of resources to the prevention of fraud and abuse. Prevention activities include prepayment reviews, site visits, terminations, and sanctions. For SFY , the return on investment demonstrates that funding to support detection and investigation has been well directed. AHCA s MPI documented that for every dollar spent to avoid costs, almost four dollars are saved ($3.9:1). In addition, for every dollar spent on recovery efforts, MPI has been able to recover nearly ten dollars ($9.8:1). DPAF has documented (SFY ) that for every dollar spent to fund their operations (both state and federal shares), they provide a return of $6.08 in benefits saved/denied, prosecuted, or collected through their partner agencies (DCF, Department of Education- Office of Early Learning, DOH, and the Social Security Administration). Similarly, during SFY , for every dollar of General Revenue expended, MFCU recovered $7.39. Given these Return on Investment (ROI) figures, it is justifiable to direct more resources to combating fraud and abuse in order to increase returns to General Revenue and to prevent unnecessary expenditures. Although surplus General Revenue funds have not been available in recent years to do this, the Strike Force believes it important to continue to explore legislative appropriations and other funding sources to support Strike Force administrative and operational costs and the anti-fraud projects it supports as a body. Recommendation #1. Secure funding to support the administrative and operational costs of the Strike Force in order that they can continue to coordinate and enhance interagency communications and support the implementation of the other recommendations identified here. Recommendation #2. Continue the efforts of the Strike Force Grant Committee to identify and facilitate procurement of funding for agencies for antifraud activities. Recommendation #3. Secure funding that can be used to leverage existing resources by providing seed grants for anti-fraud initiatives. Priority Activity Area 2: Seek and Implement Technology Solutions A major strength in the Medicaid and public assistance service systems is the prolific availability of data on recipient applicants and Medicaid claims. Unfortunately, there are a number of weaknesses that compromise the ability to make the best use of this data. This is particularly critical in efforts to detect criminal behavior patterns. Currently, the technology is not in place that connects all the databases that contain health care fraud and related data. Section (38)(b), Florida Statutes, requires AHCA to develop a strategic plan to connect these databases. In December 2010, AHCA developed a Strategic Plan for Data Connectivity of Health Care Fraud Databases. This working strategic plan provided goals and objectives 33

34 aligned with the strategic priorities provided in Section (38)(b), Florida Statutes. These priorities serve as drivers for combating fraud and abuse in the Florida Medicaid program by addressing detection and prevention activities, as well as methods to recover improper payments to Medicaid providers. AHCA designed the plan to be a dynamic document that can be adjusted to meet the needs of an ever changing Medicaid service system. Recommendation #4. Facilitate funding requests and/or advocate for legislative appropriations to support the implementation of AHCA s Data Connectivity Plan. During the past fiscal year, the agency revised the Strategic Plan to document new databases that were identified that could assist in the fight against health care fraud and abuse, as well as to identify new opportunities to connect databases storing health care fraud related information. The revised Strategic Plan was issued on March 7, In AHCA s 2010 data connectivity plan update, there were 14 databases identified and the inventory continues to grow as more agencies are engaged in this endeavor. Recommendation #5. Make better use of available data by completing an inventory of available databases, the owners of the databases, the relevance to anti-fraud efforts, the data they contain, and the restrictions/limitations on access. This is necessary to begin the process of ensuring that data is shared between agencies in the most efficient means available to prevent, detect and recoup funds lost to fraud, waste and abuse within the Medicaid and public assistance program delivery systems. In addition, a recent bi-annual audit from the Office of Program Policy Analysis and Government Accountability (OPPAGA) recommended that AHCA expand its detection tools to include neural networking and other advanced techniques for detecting emerging fraud and abuse patterns. Recent pilot projects that used link analyses have demonstrated the value of identifying connections between information maintained in various diverse databases on providers and recipients in detecting fraudulent activity. These link analyses can be facilitated with certain additional standard data elements. Recommendation #6. Track affiliated owner and business managers, (and others) of pain clinics, pharmacies and other sources of medical supplies/ drugs to enable link analyses that could identify potential fraud. One standard data element on providers that is needed to link provider information across databases is the National Provider Identifier. Currently, DOH and AHCA do not collect this information because statutory authority is required to enable them to do so. Recommendation #7. Request statutory authority to enable AHCA and DOH to collect the Standard National Identifier for practitioners to enable link analyses that could identify potential fraud. It is important to the Strike Force efforts that every consideration is given to providing the resources to incorporate such analytics or predictive modeling software into any upgrades to databases that help to prevent, detect, investigate and prosecute fraud as well as to recoup wrongful payments. In the immediate future, this would include the incorporation of such technology into AHCA s case management system replacement, which is underway. Recommendation #8. Incorporate advanced analytics in upgrades to information systems. 1. Support LBRs for Identity Verification technology, Asset Verification technology and advanced analytics in the Medicaid Eligibility System Replacement for DCF. Priority Activity Area 3: Maintain/Enhance Communications A major role that the Strike Force plays in the fight against Medicaid and public assistance fraud is as facilitator of intra- and inter-agency coordination and communications. This communication must be facilitated among all the stakeholders with an interest in eliminating fraud. Recommendation #9. Incorporate routine reports to the Strike Force members on suggestions and feedback from the front line staff on what needs to be done to improve our inter-agency efforts to eliminate Medicaid and public assistance fraud and recover state and federal funds Recommendation #10. Expand participation on Strike Force working committees to include other public assistance agencies (e.g., Department of Education, Agency for Persons with Disabilities). Recommendation #11. As part of the overall efforts to reduce Medicaid and public assistance fraud, the Strike Force needs to more aggressively pursue relationships with the media and keep them informed of activities and outcomes from the Strike Force and member agencies. Part of this effort needs to entail 34

35 public awareness of the impact of perpetrators on lawabiding citizens. Recommendation #12. In conjunction with the efforts to enhance media relations on the problem of Medicaid and public assistance fraud, the Strike Force needs to reach out to community groups, organizations and entities to engage their assistance in efforts to educate the public on the impact of Medicaid and public assistance fraud on law-abiding citizens. Priority Activity Area 4: Enhanced Prevention and Detection This has been an area of emphasis for the Strike Force and member agency staff continue to identify critical activities that will enhance prevention efforts. Track, Oversee and Solve Fraud Issues in the Transition to Managed Care Recommendation #13. As the state moves to statewide Medicaid managed care, ensure that new, anti-fraud prevention tools are put in place and that MPI and MFCU are prepared for the transition to Managed Care and the new challenges it will create for the agencies. 1. Ensure the state is paying capitated insurance payments only on behalf of qualified beneficiaries. 2. Properly enroll Medicaid applicants and quickly disenroll recipients who are no longer eligible, due to other third party insurance, a move out-of-state, a lengthy incarceration, an increase in income, or death to prevent unauthorized payments to managed care entities. 3. Ensure that benefit recoveries are coordinated so that Federal Medical Assistance Percentage refunds due do not exceed the project s collections. Conduct Anti-Fraud Policy Reviews and Make Recommendations A number of policy areas have been identified where changes could be made to enhance Strike Force agencies efforts to prevent fraud. Recommendation #14. Request statutory authority to enable DOH to conduct state and national criminal history record checks on all professions they regulate. Recommendation #15. Request expansion of the authority provided by Chapter 456, Florida Statutes, to allow DOH to conduct background screenings of all health care professionals licensed by DOH. Recommendation #16. Request expansion of AHCAs authority to restrict potentially fraudulent providers from entering the system, in particular, to minimize licensure exemptions that currently exist for health care clinics. Recommendation #17. In follow up to the SNAP Fraud Rate study, identify federal and state legislative changes needed to strengthen the program (i.e., agency oversight, stronger penalties for fraud, etc.). Prompt and Motivate Agencies to Continuously Enhance Prevention Efforts Recommendation #18. Examine the entire spectrum of public assistance delivery systems, not just at eligibility determination but also during receipt of benefits (e.g., EBT card trafficking, retailer fraud, provider billing fraud, overpayments, etc.). 1. Seek and implement solutions to identity theft in every facet of beneficiary service delivery. 2. Seek and implement employee fraud prevention and detection initiatives. 3. Seek and implement solutions to provider and retailer fraud. Priority Activity Area 5: Targeted Local Operations Partnerships Another opportunity that exists to help leverage resources is the opportunity to partner with local and federal agencies to enhance detection, investigation and enforcement efforts. There are already numerous multijurisdictional task forces and initiatives in place that enable cooperative initiatives. Supporting and growing these collaborative relationships can result in aggressive investigations into fraudulent practices from various levels. An added benefit to being more aggressive with these cases through partnerships is that illegally gained assets could be seized, preventing the perpetrators from passing along the infrastructure needed to continue the criminal activity. The Strike Force can be integral in maximizing this opportunity by advocating for and supporting these initiatives in any way possible. Having funds available through whatever funding sources the Strike Force secures would help provide resources to support these initiatives. 35

36 Sustain/Expand Federal, State Local Interagency Relationships to Improve Anti-Fraud Efforts Recommendation #19. Offer enhanced antifraud training opportunities and workshops involving both law enforcement and regulatory personnel within Florida to build collaborative, multi-agency efforts to suppress emerging fraud trends. Include training that will provide individual officers with the ability to identify indicators/evidence of Medicaid and public assistance fraud, as well as on: Recommendation #22. As a key agency in moving forward with the Targeted Local Operations Partnerships, support DPAF s Legislative request to provide them with subpoena power to assist them in the prosecution of their cases. Coordinating investigations; Ensuring successful criminal and civil prosecution; The importance of seizing assets and how to do so; and Ensuring comprehensive media coverage. Recommendation #20. Enhance communication between the criminal enforcement units and regulatory enforcement components to facilitate these efforts through the sharing of intelligence. Strike Force staff should maintain communications with all agencies that engage in these initiatives to bring awareness to problems that may arise from the perspectives of the diverse agencies involved and work with involved agencies to identify and implement solutions. Replicate Successful Models for Multi-Jurisdictional Enforcement Operations Recommendation #21. Identify high volume areas in the state where Medicaid and/or public assistance fraud is occurring, organize relevant agencies to carry out targeted enforcement initiatives and develop enforcement operational plans to launch prioritized enforcement and deterrent initiatives. The Strike Force has the agency personnel resources to identify schemes that cross program/jurisdictional lines and confront them with well-planned, data-driven, coordinated enforcement efforts. Drawing agents from local, state and federal agencies, minimally staffed and equipped initiatives can produce significant results. Conduct Anti-Fraud Policy Reviews and Make Recommendations One policy issue was identified where a change could be made to enhance the Strike Force s efforts to enhance Targeted Local Operations. 36

37 Strike Force Strategy The responses received to the survey conducted in June 2012 simply serve to more clearly define the strategy to be pursued by the Strike Force as they move forward to address fraud in public assistance and Medicaid programs. The overall strategy is a two-pronged approach that balances efforts to increase emphasis on Enhanced Prevention and Detection and Targeted Local Operations Partnerships, while providing support and advocacy to help stakeholder agencies secure and/or maintain necessary operational/infrastructure supports. This strategy is depicted below. MEDICAID & PUBLIC ASSISTANCE FRAUD STRIKE FORCE STRATEGY Enhanced Prevention and Detection Targeted Local Operations Partnerships Organizational Supports Track, Oversee and Solve Fraud Issues in the Transition to Managed Care Sustain/Expand Federal, State, Local Interangency Relationships to Improve Anti-Fraud Efforts Funding Conduct Anti-Fraud Policy Reviews and Make Recommendations Technology Replicate Successful Models for Multi-Jurisdictional Enforcement Operations Prompt and Motivate Agencies to Continuously Enhance Prevention Efforts Communications Conduct Anti-Fraud Policy Reviews and make Recommendations 37

38 38

39 Endnotes 1 Compiled from M. K. Sparrow, Chapter 4. Managed Care in License to Steal, (Westview Press, 2000), and T. L. Leap, Chapter 3. Fraud in Fee-for-Service and Managed Care in Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to do About It, (ILR Press, 2011),

40 40 NOTES

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