Protecting the integrity of Medicaid by prosecuting fraud

Florida’s attorney general works with various partners to identify and stop Medicaid fraud.

One of my office’s primary responsibilities is to investigate and prosecute cases of Medicaid fraud. When criminals defraud Florida’s Medicaid program, they are essentially stealing money from taxpayers. As Florida’s attorney general, I am dedicated to working with various partners to identify and stop Medicaid fraud.

My Medicaid Fraud Control Unit (MFCU) has eight offices throughout Florida. Florida’s Medicaid program is a more than $22.9 billion state and federal partnership that serves more than 3 million Floridians. As such, we work closely with the Agency for Health Care Administration (AHCA). AHCA carefully scrutinizes claims it receives and refers any possible fraudulent claims to MFCU. We also receive tips about Medicaid fraud directly from other sources, including citizens and other state agencies.

Typical schemes involve doctors, dentists, clinics and other healthcare providers billing for services never performed, overbilling for services provided, or billing for tests, services and products that are medically unnecessary. The MFCU also houses a Patient Abuse, Neglect and Exploitation Unit that investigates cases where elderly, ill and disabled residents are abused in nursing homes, facilities for the mentally and physically disabled and assisted care living facilities.

We also have a Complex Civil Enforcement Bureau that investigates and prosecutes qui tam cases brought by whistleblowers and by the State of Florida under the Florida False Claims Act. The Complex Civil Enforcement Bureau actively participates in multistate qui tam actions. Since I took office, our qui tam settlement figures total more than $300 million.

One unique aspect of the Florida MFCU is that we were the first state to receive a waiver from the federal government to perform data mining. This program allows us to analyze Medicaid claims data routinely and proactively in order to detect fraud. With this waiver, we mine data on the billing practices of Medicaid providers, such as hospitals, doctors, and pharmacies, and can identify trends that suggest fraud.

To protect the integrity of the Medicaid program, we continually work with local, state and federal partners. In one of our most egregious cases, my office worked with the Metropolitan Bureau of Investigation, Homeland Security Investigations, and the Florida Department of Law Enforcement to arrest a woman for committing more than $3 million in Medicaid fraud, racketeering and identify theft. The Orlando woman billed the Medicaid program for more than $3 million for services that were never provided, and she used the Medicaid funds to purchase luxury vehicles, trips and jewelry. Expenses using these ill-gotten funds include: Cadillac Escalades, a Ducati Superbike, a seven-person Carnival cruise, a trip to Cozumel, Mexico, and more than $175,000 of Luis Vuitton products. By working together with our partners, we were able to seize the defendant’s illegal assets.

My office will continue to pursue cases of Medicaid fraud and seek monetary recoveries to make the Medicaid program whole and to hold individuals responsible for committing this fraud.

Pam Bondi

Pam Bondi is the attorney general for the state of Florida.

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