News Release

HHS Announces New Tool to Help Fight Health Care Fraud in Florida

HHS Secretary Sebelius and Attorney General Holder to Co-Host Fraud Prevention Summit Tomorrow in Miami

U.S. Health and Human Services Secretary Kathleen Sebelius announced today that health care fraud fighters in the state of Florida will now have additional funding to help find potential fraud and abuse in the state’s Medicaid program through the use of Medicaid claims data.

Today, Secretary Sebelius approved Florida’s Medicaid waiver request to help fund a demonstration program that will allow the state’s Medicaid Fraud Control Unit (MFCU) to “mine” Medicaid Management Information System (MMIS) data to identify cases of potential Medicaid fraud.

Medicaid billing for many health care services in South Florida is disproportionately high compared to other parts of the country. Although significant progress has been made, fraudulent billing health care fraud continues to cost Medicaid millions of dollars. 

“To fight health care fraud, we need to coordinate all of the resources and data we can muster,” said Secretary Sebelius. “By allowing the state of Florida to use more information to find potential fraud in Medicaid, this waiver will improve Florida’s ability to effectively identify and combat fraud and abuse.”

The announcement comes in advance of the Department of Health and Human Services and Department of Justice’s first Regional Health Care Fraud Prevention Summit being held tomorrow at the Knight Center in Miami, Fla.

The summit, which will feature keynotes remarks by U.S. Attorney General Eric Holder and Secretary Sebelius, kicks off the first in a series of day-long summits bringing together a wide array of federal, state, and local partners, beneficiaries, providers, and other interested parties to discuss innovative ways to eliminate fraud within the U.S. health care system.

As part of its efforts to coordinate the fight against fraud across the nation’s health care systems, including Medicaid and Medicare, data mining will allow Florida’s MFCU to sort electronic claims through the use of statistical models and intelligent technologies to uncover patterns and relationships.  Using the identified patterns, investigators can review Medicaid claims activity and history to find abusive or abnormal use of services and billing that may be potentially fraudulent.  Data mining is done with software programs which include algorithms that automatically analyze the MMIS data.

Currently, state MFCUs are prohibited from using federal Medicaid matching funds to detect potential fraud through routine claims review procedures such as screening of claims, analysis of billing practice patterns, or routinely verifying that billed services were actually received by patients, since these functions are a primary program operation function of the state Medicaid agency.  Instead, MFCUs generally rely on referrals from the State Medicaid agency.  The waiver approved today will allow the Florida MFCU to use federal matching funds to apply sophisticated electronic data mining tools that are beyond the scope of the claims review activities normally performed by the State Medicaid agency to identify potential fraud.  

The Centers for Medicare & Medicaid Services (CMS) expects the MFCU to work closely with AHCA to ensure their collective efforts are effective. CMS will monitor the progress of this waiver in conjunction with the HHS Office of Inspector General, which has oversight of MFCUs.

“The demonstration approved today will allow Florida’s Medicaid Fraud Control Unit to take full advantage of their expertise in detecting and investigating Medicaid fraud,” said CMS Administrator Don Berwick, M.D. 

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Last revised: May 7, 2011