Florida State Offices Responsible for State Exclusions and Program Integrity

Florida Attorney General’s Medicaid Fraud Control Unit

The Florida Attorney General’s Medicaid Fraud Control Unit investigates and prosecutes providers that intentionally defraud the state’s Medicaid program through fraudulent billing practices. The MFCU investigates a wide range of misconduct originating primarily from fraudulent billing schemes. The most common schemes involve doctors, dentists, clinics and other health care providers billing for services never performed, over billing for services provided, or billing for tests, services and products that are medically unnecessary. From January 2019 to the present, the Florida MFCU has obtained more than $70 million in settlements and judgments.

Florida’s Agency for Health Care Administration (AHCA)

AHCA’s mission:

“Our mission is Better Health Care for All Floridians.  As champions of that mission, we are responsible for the administration of the Florida Medicaid program, licensure and regulation of Florida’s health facilities and for providing information to Floridians about the quality of care they receive.”

The AHCA is divided into various units and subunits that work collaboratively to fulfill the AHCA program integrity responsibilities. These include:

  1. The Office of the Inspector General.  As part of the AHCA, the Office of the Inspector General was established to provide a central point for coordination of and responsibility for activities that promote accountability, integrity, and efficiency in government pursuant to Section 20.055 of the Florida Statutes. The Office of the Inspector General is comprised of three units:  Internal Audit, Investigations, and the HIPAA Compliance Office.

    The primary mission of the mission of the Office of the Inspector General is to assist AHCA leadership in championing accessible, affordable, quality health care for all Floridians by assessing the efficiency and effectiveness of health care administration resource management.

    This mission is carried out through:
    1. Independent examination and evaluation of Agency programs, activities, and resources.
    2. Internal investigations of alleged violations of Agency policies, procedures, rules or laws.
    3. Investigation of suspected fraud and/or abuse of the state’s Medicaid program.
  2. Division of Health Quality Assurance.  The Division of Health Quality Assurance (HQA) is responsible for the regulation of 41 types of health care facilities and businesses (providers) and managed care organizations and more than 45,000 facilities/providers including health maintenance organization, nursing homes, hospitals, assisted living facilities, home health agencies, health care clinics, clinical laboratories, and others.

    Duties include:
    1. state licensure, federal certification, and criminal background checks for owners, operators and certain health care provider staff;
    2. routine and complaint inspections and plans and construction reviews for certain facilities;
    3. consumer and public information regarding health care facilities including licensure and inspection information to the public and public record requests;
    4. financial reviews and analysis for licensure and regulatory assessments; and
    5. managed care regulation, including network verification licensure, complaint investigations, subscriber grievance review, and Medicaid managed care organizations.

      Bureau of Medicaid Program Integrity (MPI).  During Fiscal Year (FY) 2017-18, the Bureau of Medicaid Program Integrity (MPI) relocated from the Office of Inspector General to the Division of Health Quality Assurance. MPI serves as the primary office within the Agency to design, coordinate, and implement the Medicaid program’s fraud, abuse, and waste prevention and detection efforts. Other functions of this office include:
      1. Recovery of overpayments;
      2. Issuance of administrative sanctions; and
      3. Referral of fraud-related cases to the Office of the Attorney General for criminal investigation.
  3. Division of Medicaid. The Division of Medicaid administers Florida’s Medicaid program and Children’s Health Insurance Program (CHIP), which provide health care services to over four million low- income children, families, elders, and people with disabilities. The Division provides the Medicaid services through the statewide Medicaid Managed Care program through which contracted health plans deliver services to their members. The Division also determines the services that are covered, sets high benchmarks for quality of health care services, and closely monitors to ensure performance, quality, and cost-effective care.

    For an overview of all AHCA units and subunits, please refer to the linked AHCA  2019 memorandum.

Statutory Authority for Exclusion

Florida’s authority to suspend and terminate providers from participation in state Medicaid programs is found in Florida Statutes Chapter 409 Section 913.  Under the terms of this statute, the AHCA is required to oversee the activities of Florida Medicaid recipients, and providers and their representatives, to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible, and to recover overpayments and impose sanctions as appropriate.

Sections 409. 913 (13) and (14) specifically address provider suspension and termination by the AHCA:  

409.913(13) The agency shall terminate participation of a Medicaid provider in the Medicaid program and may seek civil remedies or impose other administrative sanctions against a Medicaid provider, if the provider or any principal, officer, director, agent, managing employee, or affiliated person of the provider, or any partner or shareholder having an ownership interest in the provider equal to 5 percent or greater, has been convicted of a criminal offense under federal law or the law of any state relating to the practice of the provider’s profession, or a criminal offense listed under s. 408.809(4), s. 409.907(10), or s. 435.04(2). If the agency effects a termination under this subsection, the agency shall take final agency action.

409.913(14) If the provider has been suspended or terminated from participation in the Medicaid program or the Medicare program by the Federal Government or any state, the agency must immediately suspend or terminate, as appropriate, the provider’s participation in this state’s Medicaid program for a period no less than that imposed by the Federal Government or any other state, and may not enroll such provider in this state’s Medicaid program while such foreign suspension or termination remains in effect. The agency shall also immediately suspend or terminate, as appropriate, a provider’s participation in this state’s Medicaid program if the provider participated or acquiesced in any action for which any principal, officer, director, agent, managing employee, or affiliated person of the provider, or any partner or shareholder having an ownership interest in the provider equal to 5 percent or greater, was suspended or terminated from participating in the Medicaid program or the Medicare program by the Federal Government or any state. This sanction is in addition to all other remedies provided by law.

Reasons for State Action Against a Provider

Section 409. 913 (15) sets forth the many reasons that the state may take action against a provider:

  • The provider’s license has not been renewed, or has been revoked, suspended, or terminated, for cause, by the licensing agency of any state;
  • The provider has failed to make available or has refused access to Medicaid-related records to an auditor, investigator, or other authorized employee or agent of the agency, the Attorney General, a state attorney, or the Federal Government;
  • The provider has not furnished or has failed to make available such Medicaid-related records as the agency has found necessary to determine whether Medicaid payments are or were due and the amounts thereof;
  • The provider has failed to maintain medical records made at the time of service, or prior to service if prior authorization is required, demonstrating the necessity and appropriateness of the goods or services rendered;
  • The provider is not in compliance with provisions of Medicaid provider publications that have been adopted by reference as rules in the Florida Administrative Code; with provisions of state or federal laws, rules, or regulations; with provisions of the provider agreement between the agency and the provider; or with certifications found on claim forms or on transmittal forms for electronically submitted claims that are submitted by the provider or authorized representative, as such provisions apply to the Medicaid program;
  • The provider or person who ordered, authorized, or prescribed the care, services, or supplies has furnished, or ordered or authorized the furnishing of, goods or services to a recipient which are inappropriate, unnecessary, excessive, or harmful to the recipient or are of inferior quality;
  • The provider has demonstrated a pattern of failure to provide goods or services that are medically necessary;
  • The provider or an authorized representative of the provider, or a person who ordered, authorized, or prescribed the goods or services, has submitted or caused to be submitted false or a pattern of erroneous Medicaid claims;
  • The provider or an authorized representative of the provider, or a person who has ordered, authorized, or prescribed the goods or services, has submitted or caused to be submitted a Medicaid provider enrollment application, a request for prior authorization for Medicaid services, a drug exception request, or a Medicaid cost report that contains materially false or incorrect information;
  • The provider or an authorized representative of the provider has collected from or billed a recipient or a recipient’s responsible party improperly for amounts that should not have been so collected or billed by reason of the provider’s billing the Medicaid program for the same service;
  • The provider or an authorized representative of the provider has included in a cost report costs that are not allowable under a Florida Title XIX reimbursement plan after the provider or authorized representative had been advised in an audit exit conference or audit report that the costs were not allowable;
  • The provider is charged by information or indictment with fraudulent billing practices or an offense referenced in subsection (13). The sanction applied for this reason is limited to suspension of the provider’s participation in the Medicaid program for the duration of the indictment unless the provider is found guilty pursuant to the information or indictment;
  • The provider or a person who ordered, authorized, or prescribed the goods or services is found liable for negligent practice resulting in death or injury to the provider’s patient;
  • The provider fails to demonstrate that it had available during a specific audit or review period sufficient quantities of goods, or sufficient time in the case of services, to support the provider’s billings to the Medicaid program;
  • The provider has failed to comply with the notice and reporting requirements of s. 409.907;
  • The agency has received reliable information of patient abuse or neglect or of any act prohibited by s. 409.920; or
  • The provider has failed to comply with an agreed-upon repayment schedule.

Section 59G-9.070 Administrative Sanctions on Providers, Entities, and Persons of the Florida Administrative Code, sets forth the required sanctions for each of these offenses, which are imposed in addition to the recoupment of any overpayment.

Exclusion Sanctions

Section 409.913 (16) sets forth the sanctions which can be imposed:

(16) The agency shall impose any of the following sanctions or disincentives on a provider or a person for any of the acts described in Section 409. 913 (15) above:

  • Suspension for a specific period of time of not more than 1 year. Suspension precludes participation in the Medicaid program, which includes any action that results in a claim for payment to the Medicaid program for furnishing, supervising a person who is furnishing, or causing a person to furnish goods or services.
  • Termination for a specific period of time ranging from more than 1 year to 20 years. Termination precludes participation in the Medicaid program, which includes any action that results in a claim for payment to the Medicaid program for furnishing, supervising a person who is furnishing, or causing a person to furnish goods or services.
  • Imposition of a fine of up to $5,000 for each violation. Each day that an ongoing violation continues, such as refusing to furnish Medicaid-related records or refusing access to records, is considered a separate violation. Each instance of improper billing of a Medicaid recipient; each instance of including an unallowable cost on a hospital or nursing home Medicaid cost report after the provider or authorized representative has been advised in an audit exit conference or previous audit report of the cost unallowability; each instance of furnishing a Medicaid recipient goods or professional services that are inappropriate or of inferior quality as determined by competent peer judgment; each instance of knowingly submitting a materially false or erroneous Medicaid provider enrollment application, request for prior authorization for Medicaid services, drug exception request, or cost report; each instance of inappropriate prescribing of drugs for a Medicaid recipient as determined by competent peer judgment; and each false or erroneous Medicaid claim leading to an overpayment to a provider is considered a separate violation.
  • Immediate suspension, if the agency has received information of patient abuse or neglect or of any act prohibited by s. 409.920. Upon suspension, the agency must issue an immediate final order under s. 120.569(2)(n).
  • A fine, not to exceed $10,000, for a violation of paragraph (15)(i) (which relates to submission of false or incorrect information provided when ordering or prescribing of good and services for Medicaid patients, enrolling as a Medicaid program provider, seeking prior authorizations for patient services, or falsifying financial reports);
  • Imposition of liens against provider assets, including, but not limited to, financial assets and real property, not to exceed the amount of fines or recoveries sought, upon entry of an order determining that such moneys are due or recoverable.
  • Prepayment reviews of claims for a specified period of time.
  • Comprehensive follow-up reviews of providers every 6 months to ensure that they are billing Medicaid correctly.
  • Corrective action plans that remain in effect for up to 3 years and that are monitored by the agency every 6 months while in effect.
  • Other remedies as permitted by law to effect the recovery of a fine or overpayment.

If a provider voluntarily relinquishes its Medicaid provider number or an associated license, or allows the associated licensure to expire after receiving written notice that the agency is conducting, or has conducted, an audit, survey, inspection, or investigation and that a sanction of suspension or termination will or would be imposed for noncompliance discovered as a result of the audit, survey, inspection, or investigation, the agency shall impose the sanction of termination for cause against the provider.

Under Section 409.913 (17), the AHCA may take into consideration certain factors in determining the appropriate agency action. In determining the appropriate administrative sanction to be applied, or the duration of any suspension or termination, the agency shall consider:

  • The seriousness and extent of the violation or violations.
  • Any prior history of violations by the provider relating to the delivery of health care programs which resulted in either a criminal conviction or in administrative sanction or penalty.
  • Evidence of continued violation within the provider’s management control of Medicaid statutes, rules, regulations, or policies after written notification to the provider of improper practice or instance of violation.
  • The effect, if any, on the quality of medical care provided to Medicaid recipients as a result of the acts of the provider.
  • Any action by a licensing agency respecting the provider in any state in which the provider operates or has operated.
  • The apparent impact on access by recipients to Medicaid services if the provider is suspended or terminated, in the best judgment of the agency.

The agency shall document the basis for all sanctioning actions and recommendations.

(18) The agency may take action to sanction, suspend, or terminate a particular provider working for a group provider, and may suspend or terminate Medicaid participation at a specific location, rather than or in addition to taking action against an entire group.

Florida Termination and Sanction Lists

Exclusion actions in Florida, unlike other states that closely mirror federal law, is founded upon a complex set of legal authorities that are captured in multiple statutes. Checking Florida exclusion lists can be equally daunting. There are actually two lists that need to be reviewed. Florida maintains lists of both providers who have been financially sanctioned by the state as well as provides who have been terminated for cause from participation in Florida’s Medicaid programs.

The Sanctioned List contains the name, address and license number of persons, providers or entities sanctioned by the agency.    In some circumstances, the agency has discretion to, and in others must, impose a sanction against a person, provider or entity, for failure to comply with Medicaid laws, rules or policies.  Sanctions may vary significantly, depending on the nature and seriousness of the violation.  By way of example, sanctions may include, but are not limited to, corrective actions such as education or self‐audits, monetary penalties (i.e., fines), suspensions and terminations.    [See 59G‐9.070, F.A.C., Administrative Sanctions on Providers, Entities and Persons and §409.913, F.S.]

The Terminated List contains the name, address and license number of persons, providers or entities which are terminated for cause from participation in the Medicaid program.    Such terminations are imposed by the agency under its statutory and/or regulatory authority, and are commonly referred to, and known as, “for cause” or “with cause” terminations.    [See 59G‐9.070, F.A.C., Administrative Sanctions on Providers, Entities and Persons and §409.913, F.S.].   

This can make the exclusion screening for Florida confusing since a provider can still be eligible to participate in a Medicaid program even though they are listed in the Florida database as a result of monetary sanctions against them.  A 2009 memo by the AHCA attempted to clarify the distinctions between these two types of administration actions.

Florida Exclusion Lists

The AHCA Public Record Search offers two types of lists – Legal Orders and Statements of Deficiencies. Below is the screenshot of the search criteria available for Legal Orders:

Legal Orders

Legal Ord“Legal Orders” are decisions rendered by the Agency on a legal matter. There are two types of legal orders:

  1. Final Orders: “Final Orders” are legal orders that decide a case or claim on a final basis. Final Orders made available through this web page may not always reflect the final disposition of a matter since they may have been appealed and the appeal may not yet be finalized.
  2. Emergency Orders: “Emergency Orders” are orders that place temporary restrictions on a facility or provider due to the presence of conditions that constitute an immediate danger to the health, safety and welfare of patients or residents at that facility. The temporary restrictions may be lifted once the facility or provider has taken the necessary steps to eliminate the presence of those conditions, although further disciplinary action may be taken by the Agency.

Statements of Deficiencies

“Statement of Deficiencies” displays violations of a regulation that are found during an inspection or investigation of a health care provider. Before penalties for a deficiency are imposed, a licensee has the opportunity to contest Agency findings. Statement of deficiency reports may contain protected health information (PHI) so the state auto-redacts potential PHI to permit public access to these reports without breaching patient confidentiality.  Below is the screenshot of the search criteria available Statements of Deficiency:

However, there is a process that may expedite searching multiple Florida lists for information about whether a provider is eligible to provide Medicaid services. On the Florida Medicaid Web Portal you can access the Provider Master List.  Under the Managed Care menu, you will want to select Provider Master List, which can be found under the Registration column (third from the right). You will then need to select the Provider Master List spreadsheet link in the “Provider Information Reports” section, and unzip the Excel file. Providers that have an E listed next to their Medicaid IDs/names are considered by AHCA to be ineligible to provide services.

Provider Reinstatement

Similar to federal law, Florida providers must apply for reinstatement after their period of suspension or termination expires. As stated in Florida Administrative Code Section 59G-9.070(6):

(6) Additional requirements regarding suspension and termination.

      (a) For purposes of this rule a “suspension” precludes participation for one year, or such shorter period of time as is set forth in this rule. The suspension period begins from the date of the Final Order that imposes the Agency action.

  1. To resume participation following the suspension period, a written request must be submitted to the Agency’s Bureau of Medicaid Program Integrity seeking to be reinstated in the Medicaid program. The request must include a copy of the notice of suspension and a statement regarding whether the violation(s) that brought rise to the suspension have been remedied. If the provider, entity, or person was not enrolled in the Medicaid program at the time of the suspension, the request must also include a complete and accurate provider enrollment application, even if the person or entity seeks only to prescribe, or otherwise order or authorize goods or services, and does not seek to directly furnish goods or services to Medicaid recipient; the application will be processed, and accepted or denied in the standard course of business by the Agency.
  2. Participation in the Medicaid program may not resume until written confirmation is issued from the Agency indicating that participation has been authorized. Where a Medicaid provider application is required, authorization is at the point where the person or entity is enrolled as a provider; if the application is not granted, the person or entity may not resume participation.

(b) For purposes of this rule, a “termination” shall preclude participation in the Medicaid program for twenty years from the date of the Agency action. The termination period begins from the date of the Final Order that imposes the Agency action, unless the termination is an “immediate termination.” An immediate termination period begins from the date of notice of the termination.

To resume participation, the provider, entity, or person must submit a complete and accurate provider enrollment application, which will be processed, and accepted or denied in the standard course of business by the Agency. In addition to the application, the provider, entity, or person must include a copy of the notice of termination issued by the Agency, and a written acknowledgement regarding whether the violation(s) that brought rise to the termination has been remedied.

The Florida template Medicaid contract with managed care organizations includes the several provisions related to exclusions and screening. The 2020 Florida Template Medicaid Health Plan Contract specifically requires contracted managed care organizations to check monthly the AHCA listing of suspended and terminated providers to ensure that they do not include any non-Medicaid eligible providers in its network.

Attachment II – Core Provisions

Section X. Administration and Management

F. Fraud and Abuse Prevention

4. Compliance Plan and Anti-Fraud Plan

d. At a minimum, the Managed Care Plan’s compliance plan, anti-fraud plan, and fraud and abuse procedures shall comply with s. 409.91212, F.S., and with the following:

(14) Not knowingly employ or contract with individuals or entities debarred or excluded from participation in any federal health care program under ss. 1128 and 1128A of the Social Security Act, nor with an individual or entity who is an affiliate, as defined in the Federal Acquisition Regulation at 48 CFR 2.101, of a person described in 42 CFR 438.610 (a)(1); or subcontractors on the discriminatory vendor list maintained by the Department of Management Services in accordance with s. 287.134, F.S.; (42 CFR 438.808(a) and (b)(2); 42 CFR 431.55(h); 42 CFR 438.610(b); ss. 1128(b)(8) and 1903(i)(2) of the Social Security Act; 42 CFR 1001.1901(c); 42 CFR 1002.3(b); State Medicaid Director Letters 6/12/08 and 1/16/09; Executive Order No. 12549)

(15) On at least a monthly basis check current staff, subcontractors and providers against the federal LEIE and the federal SAM (includes the former EPLS) or their equivalent, to identify excluded parties. The Managed Care Plan shall also check monthly the Agency’s listing of suspended and terminated providers at the Agency website below, to ensure the Managed Care Plan does not include any non-Medicaid eligible providers in its network: http://apps.ahca.myflorida.com/dm_web. The Managed Care Plan shall also conduct these checks during the process of engaging the services of new employees, subcontractors and providers and during renewal of agreements and recredentialing. The Managed Care Plan shall not employ or contract with an entity that is in nonpayment status or is excluded from participation in federal health care programs under ss. 1128 and 1128A of the Social Security Act; (42 CFR 438.214(d)(1)).

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