Florida Statutes
Part III - Medicaid (Ss. 409.901-409.9205)
409.91212 - Medicaid managed care fraud.

(1) Each managed care plan, as defined in s. 409.920(1)(e), shall adopt an anti-fraud plan addressing the detection and prevention of overpayments, abuse, and fraud relating to the provision of and payment for Medicaid services and submit the plan to the Office of Medicaid Program Integrity within the agency for approval. At a minimum, the anti-fraud plan must include:
(a) A written description or chart outlining the organizational arrangement of the plan’s personnel who are responsible for the investigation and reporting of possible overpayment, abuse, or fraud;
(b) A description of the plan’s procedures for detecting and investigating possible acts of fraud, abuse, and overpayment;
(c) A description of the plan’s procedures for the mandatory reporting of possible overpayment, abuse, or fraud to the Office of Medicaid Program Integrity within the agency;
(d) A description of the plan’s program and procedures for educating and training personnel on how to detect and prevent fraud, abuse, and overpayment;
(e) The name, address, telephone number, e-mail address, and fax number of the individual responsible for carrying out the anti-fraud plan; and
(f) A summary of the results of the investigations of fraud, abuse, or overpayment which were conducted during the previous year by the managed care organization’s fraud investigative unit.

(2) A managed care plan that provides Medicaid services shall:
(a) Establish and maintain a fraud investigative unit to investigate possible acts of fraud, abuse, and overpayment; or
(b) Contract for the investigation of possible fraudulent or abusive acts by Medicaid recipients, persons providing services to Medicaid recipients, or any other persons.

(3) If a managed care plan contracts for the investigation of fraudulent claims and other types of program abuse by recipients or service providers, the managed care plan shall file the following with the Office of Medicaid Program Integrity within the agency for approval before the plan executes any contracts for fraud and abuse prevention and detection:
(a) A copy of the written contract between the plan and the contracting entity;
(b) The names, addresses, telephone numbers, e-mail addresses, and fax numbers of the principals of the entity with which the managed care plan has contracted; and
(c) A description of the qualifications of the principals of the entity with which the managed care plan has contracted.

(4) On or before September 1 of each year, each managed care plan shall report to the Office of Medicaid Program Integrity within the agency on its experience in implementing an anti-fraud plan, as provided under subsection (1), and, if applicable, conducting or contracting for investigations of possible fraudulent or abusive acts as provided under this section for the prior state fiscal year. The report must include, at a minimum:
(a) The dollar amount of losses and recoveries attributable to overpayment, abuse, and fraud.
(b) The number of referrals to the Office of Medicaid Program Integrity during the prior year.

(5) If a managed care plan fails to timely submit a final acceptable anti-fraud plan, fails to timely submit its annual report, fails to implement its anti-fraud plan or investigative unit, if applicable, or otherwise refuses to comply with this section, the agency shall impose:
(a) An administrative fine of $2,000 per calendar day for failure to submit an acceptable anti-fraud plan or report until the agency deems the managed care plan or report to be in compliance;
(b) An administrative fine of not more than $10,000 for failure by a managed care plan to implement an anti-fraud plan or investigative unit, as applicable; or
(c) The administrative fines pursuant to paragraphs (a) and (b).

(6) Each managed care plan shall report all suspected or confirmed instances of provider or recipient fraud or abuse within 15 calendar days after detection to the Office of Medicaid Program Integrity within the agency. At a minimum the report must contain the name of the provider or recipient, the Medicaid billing number or tax identification number, and a description of the fraudulent or abusive act. The Office of Medicaid Program Integrity in the agency shall forward the report of suspected overpayment, abuse, or fraud to the appropriate investigative unit, including, but not limited to, the Bureau of Medicaid program integrity, the Medicaid fraud control unit, the Division of Public Assistance Fraud, the Division of Investigative and Forensic Services, or the Department of Law Enforcement.
(a) Failure to timely report shall result in an administrative fine of $1,000 per calendar day after the 15th day of detection.
(b) Failure to timely report may result in additional administrative, civil, or criminal penalties.

(7) The agency may adopt rules to administer this section.
History.—s. 12, ch. 2010-144; s. 9, ch. 2016-165.

Structure Florida Statutes