Florida increases efforts to combat public benefits fraud

Published: June 04, 2013

Social Services

Florida’s health and human services departments are taking many strides to combat fraud and abuse of public assistance programs.

The Department of Children and Families (DCF) awarded a $3 million contract to LexisNexis to provide identification verification services to the more than 11 million applicants the department receives annually for the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid, and Refugee Services programs. The verification and authentication solution is integrated into DCF’s Automated Community Connection to Economic Self Sufficiency (ACCESS) system – Florida’s integrated eligibility system provided by Deloitte.

LexisNexis will verify the identities of both new applications and those seeking recertification for eligibility every six months. If an applicant cannot be verified, the system will flag the application and it will be sent to DCF for further investigation.

Florida’s fraud prevention project is the first of its kind in the nation. “Implementing technology that has been successfully used in the private sector will allow us to catch more of these cheats on the front-end while we continue to utilize modern investigative strategies to fight fraud in Florida’s public assistance programs,” said DCF Secretary David Wilkins in a press release.

DCF received proposals from eight vendors, with proposed costs ranging from $1.35 million to $8.045 million. Deltek subscribers can access bid tabulation information here.

According to the 2012 Strike Force Annual Report, overpayments identified by the AHCA Bureau of Medicaid Program Integrity (MPI) totaled approximately $36.1 million for SFY 2011-12. AHCA referred 71 fraud cases to the Office of the Attorney General (OAG), Medicaid Fraud Control Task Force (MFCU), which recovered nearly $162 million for the year – a 46 percent increase from the previous year. Further, AHCA’s third-party liability (TPL) contractors recovered an additional $148 million using computer-assisted analyses of paid claims.

DCF is not the only state agency looking to combat fraud and abuse with IT solutions. As Florida transitions its Medicaid model from fee-for-service to managed care, OAG’s MFCU as well as the state’s Medicaid Public Assistance Fraud Strike Force have been in talks with states that previously made the transition to managed care to learn best practices.

Virginia’s MFCU contracted a firm to perform an audit of providers and refer suspected fraud to the MFCU, whose auditors review and analyze referrals. In Arizona, the Office of the Inspector General’s Medicaid Fraud Unit investigates fraud; the state’s Medicaid Managed Care Organization (MCO) is not allowed to conduct fraud investigations. At a recent meeting of the Strike Force, Florida Attorney General Pam Bondi and vice-chair of the Strike Force “expressed concern that fraud will only get harder to detect as more sophisticated, complex fraud schemes are devised.” OAG is working on a request for proposals (RFP) for an anti-fraud technology solution.

In another fraud-prevention effort, Florida’s Agency for Persons with Disabilities (APD) is planning to procure an electronic visit verification and data management system to combat fraud, waste and abuse of home-based health care services. The solution will allow APD to verify when and where a service is being provided and the actual amount of time the provider spends with the consumer. Currently, APD does not receive a systematic confirmation of service authorization and is not alerted if a consumer goes over his/her allotted units.

According to a request for information (RFI), “electronic visit verification which will ensure services are delivered as agreed upon and at the times and locations authorized by the agency. This component of the system will feed into an electronic client central record that will contain the key data needed to monitor client progress as well as agency and provider performance and measurable outcomes.”

Analyst’s Take

While fraud and abuse detection systems are not a new technology in the Medicaid world, Florida’s verification system represents one of the first efforts to simultaneously combat fraud across multiple benefit programs, thus helping to eliminate duplicated, redundant systems that are often developed for health and human services programs.

With streamlined systems that determine eligibility for multiple benefits programs at once comes the potential for fraudulent access of multiple benefit programs; therefore, verification systems that can span multiple benefit programs are needed. Further, focusing fraud prevention efforts on the front end of service provision saves the state time, money and human resources by preventing the fraudulent transfer of benefits entirely, rather than recouping fraudulently transferred funds after the fact.

Vendors can expect to see other states following the coattails of Florida’s fraud prevention efforts, particularly those states with existing integrated eligibility systems such as Texas and Illinois. Vendors may also see a spike in consulting opportunities to review and analyze existing fraud prevention measures taken by states and make recommendations for solutions and methodologies the state should implement to combat fraudulent activity.