Florida AG wants to fight Medicaid fraud with statewide data mining

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Florida wants to implement a statewide pilot program that will allow the Medicaid Fraud Control Unit (MFCU) in Attorney General Bill McCollum's office to mine data for outliers, anomalies or other indicators of potential fee-for-service Medicaid fraud. McCollum and Secretary Tom Arnold of the Florida Agency for Health Care Administration (AHCA) have submitted a formal waiver request to the federal government, reports Health News Florida. Florida officials have been in informal talks with federal officials for more than a year, and they anticipate that the waiver request will be approved--making Florida "the first in the nation to have a program granting a state attorney general authority to routinely review this data," said McCollum.

The waiver is needed because federal regulations currently prohibit state MFCUs like Florida's from mining data to search out fraudulent activity. Instead, the Florida AHCA has to do the data mining and refer cases to the state MFCU.

Florida anticipates a Jan. 1, 2011, launch date for the pilot. "Areas of particular concern that the demonstration would address include hospital services, nursing homes, pharmacy, physician services, home and community-based waivers, payments to assisted living facilities, and home health services," explained the waiver request. "In addition, given that Florida has over 3.03 million seniors (age 65+), which is second in the country to California, we believe that any fraud and abuse detection efforts could focus on population-specific activities, including dual-eligible beneficiaries, and this could benefit Medicare."

If Florida shows that the investigative and prosecutorial experience of MFCU analysts can be applied successfully to data mining to find patterns indicative of fraud and ultimately increase fraud-related convictions and overpayment recoveries, "the demonstration may serve as a model for the rest of the nation," said the waiver request.

To learn more:
- read this Health News Florida article
- read the McCollum's press release
- access a copy of the waiver request here

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