AHCA Secretary Issues Important Notice on Policy Changes Related to Overpayment of Medicaid Funds and Medicaid Fraud - Over the holidays, AHCA Secretary Tom Arnold sent the notice that follows. Please read it carefully if you are a Medicaid provider.

Medicaid fraud and abuse and any over-payment of Medicaid funds take away scarce resources from those who provide necessary and appropriate care.  The purpose of this notice is to draw your attention to two provisions of Florida law that were amended during the 2009 Legislative Session.  Senate Bill 1986 amended, among other provisions, sections 409.913(27) and (30), Florida Statutes.  I am bringing these changes to your attention as they may have a significant impact on how members of your association conduct business with the Agency following notice of a Medicaid overpayment.

While the Agency has always had the authority to withhold Medicaid reimbursements as a tool for collection of overpayments, the changes to the law now require that we withhold all Medicaid reimbursements beginning 30 days following notice of an alleged overpayment.  The law provides an exception to the withholding if a provider has made full repayment or established a satisfactory repayment agreement with the Agency.  What this means for Medicaid providers is that involuntary withholds of full Medicaid reimbursements will be initiated following all final audit reports which allege that an overpayment has occurred.  

We want providers to understand that the withholding of payment will be initiated more quickly following issuance of an overpayment notification.  Additionally, the withholding will occur even where the provider has sought an administrative hearing to challenge the overpayment findings.  Providers are encouraged to contact the Agency (contact information is included in the final audit reports) immediately following a notice of overpayment to arrange for repayment (either in full or via a repayment agreement) to avoid the involuntary withhold process.

Additionally, the Agency is now required to terminate a provider's participation in the Medicaid program if the provider fails to reimburse an overpayment within 35 days after the date of the final order, unless the provider and the Agency have entered into a repayment agreement.  Such a termination is not subject to appeal.  Providers who may have previously relied upon the withhold process to satisfy their debts to the Agency should be advised that an involuntary withhold does not satisfy the statutory obligation to repay in full or enter into a satisfactory repayment agreement.  Thus, if the involuntary withhold results in the debt ultimately being satisfied, the provider will still be terminated from the program.

The Florida Medicaid program is fortunate that the vast majority of its providers are honest and provide high-quality care.  Unfortunately, the few bad players create a need for bold efforts.   This new law also provides the Agency with new tools to combat Medicaid fraud and abuse by adding penalties and the authority to impose sanctions and suspend or revoke licenses. 

Finally, the law creates a provision whereby persons who report Medicaid fraud may be entitled to a reward up to 25 percent of the amount recovered, up to a maximum of $500,000 per case, if a criminal case results in a fine, penalty or a forfeiture of property.  Tips about suspected fraud can be reported by calling the Attorney General's Fraud Hotline at 1-866-966-7226 or the Agency's Consumer Call Center at 1-888-419-3456.  Other communication initiatives are in progress, including a mailing to Medicaid recipients to heighten awareness and encourage recipients to report fraud.   Citizens may also report fraud online by visiting our Web site, http://ahca.myflorida.com and clicking the "Report Fraud" button. Click on the brochure and poster to view these items for use in promoting this effort.

New Alliance Seeks to Improve Long-Term Services - The Long-Term Quality Alliance, which was formally introduced this week, will focus on improving the quality of the experience of consumers and family caregivers in both nursing home and home health care settings. "Current quality efforts tend to focus on clinical services delivered in nursing homes and often overlook the perspectives of consumers and family caregivers," said Alliance Chair Mary Naylor in a statement.

The alliance's key priorities will include identifying promising performance and quality measures; recommending ways to implement those measures in clinical and community settings; proposing ways to reinforce current quality initiatives; and achieving improvements through pilot programs, demonstration projects, and other efforts. It will focus initially on two issues: improving care transitions and reducing unnecessary hospitalizations.

The 29-member board of directors is comprised of health, consumer, and policy experts. They include Mark McClellan, the former administrator of the Centers for Medicare & Medicaid services; Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging; and other long-term care leaders and advocates. The board's inaugural meeting will take place Jan 28.

Source: McKnight's LTC Daily News, January 06, 2010