Florida AG aims to combat Medicaid fraud via data mining
Attorney General (AG) Bill McCollum and the Florida Agency for HealthCare Administration's Secretary Tom Arnold have submitted a formal request to the Centers for Medicare & Medicaid Services (CMS) for a waiver from the federal government which, if granted, would launch a Florida pilot data mining program to combat Medicaid fraud.
The waiver would permit the AG's Medicaid Fraud Control Unit (MFCU) increased authority to access data from the Florida Medicaid program so the unit can generate its own leads for investigations.

“We believe that this waiver will significantly improve the effectiveness of investigation and prevention of Medicaid fraud in Florida,” wrote the public officials. “During the fiscal year 2010-2011, the Medicaid program will serve more than 2.7 million enrollees, with total program expenditures of approximately $18.7 billion. There is an immediate critical need to employ all available resources to ensure the integrity of Medicaid services and payments.”

Currently, Florida's MFCUs are prohibited by federal code from proactively reviewing data to determine whether fraud is taking place. The waiver would allow McCollum's MFCU to mine data on Medicaid's fee-for-services program to identify any outliers, anomalies or other indicators of fraud.

The AG has written several letters to the federal government requesting a waiver of the federal regulation and has worked on this initiative with the Agency for HealthCare Administration for over a year. According to the waiver request, Florida is prepared to implement data mining activities to develop potential fraud referrals by Jan. 1, 2011.

Prepared to begin coordination upon approval from the CMS, the MFCU would be able to review the billing practices of Medicaid providers such as doctors, pharmacies and hospitals, stated a release from the attorney general's office.

A copy of the formal request and an outline of the plan for the waiver is available here.