On September 16, 2014, Florida’s Agency for Health Care Administration (AHCA) issued a notice to Medicaid providers informing that “in the upcoming weeks the Agency will increase its efforts to ensure that providers are repaying overpayments”, while also reminding Medicaid providers of “their obligation to promptly refund moneys due to [AHCA], including any moneys received in error or in excess of the amount to which the provider is entitled from the Medicaid program, or any moneys due as a result of the imposition of a fine or other fees or costs. (See, Section 409.907(3)(g), Florida Statutes and paragraph 5(g) of the Non-institutional Medicaid provider agreement).”
In 2010, AHCA amended Rule 59G-9.070, F.A.C., to increase the severity of punitive and monetary sanctions for failing to comply with Medicaid program requirements. Under the revised rule, any provider who fails to comply with the terms of an approved repayment schedule will be fined $5,000 and suspended until the violation is corrected,for the first offense. If the provider remains in noncompliance after 30 days, the Medicaid provider will be terminated. According to OPPAGA, in Fiscal Years 2011-12 and 2012-13 145 providers were suspended; 194 providers were terminated from participation in the Florida Medicaid Program; and 433 providers with no identified overpayments were fined $4.9 million for failing to provide documentation requested by AHCA.
Providers who have outstanding debts to the Agency may find that their future Medicaid reimbursements are withheld to offset the debt. However, if the Agency is withholding reimbursements without a written repayment agreement, the provider is not in compliance with the obligation to repay moneys due and may still be terminated from participation in the Medicaid program.
Florida Medicaid providers sanctioned with termination, are prohibited from participating in the Medicaid program as enrolled providers or as Medicaid managed care network providers. See, Rule 59G-9.070 (2)(s), F.A.C., and Sections 409.913(25)(c) and 409.913(30), Florida Statutes.
Thus, it is imperative that all Medicaid providers under investigation by AHCA immediately communicate with the Agency to delineate the scope of the investigation, become informed of the impending time frames and understand the administrative process in order to preserve their due process rights.
Our firm has represented numerous Medicaid providers facing costly overpayments. Mr. Gaitan, who mainly handles these cases for the firm, advises providers to seek legal advise immediately upon receiving the first communication from AHCA, Delmarva Foundation or SafeGuard Services regarding a possible overpayment. Early intervention by an experienced attorney can help to narrow the scope of the overpayment and reduce the amount owed to AHCA, or, in some cases, may lead to resolution without enforcement action. More importantly, any provider who receives a Final Audit Report (F.A.R.) must respond to the overpayment finding within 21 days or relinquish their right to appeal the Agency’s conclusions.
Any Medicaid provider who is facing an overpayment claim because of a self-audit review or AHCA audit who wishes to speak with a health care attorney is encouraged to call our firm at 786.440.8115.