June 30, 2014
Strike Force Final Report 1

2013-2014
Chairman, Jeff Atwater,
Chief Financial Officer,
Florida Department of Financial Services
Vice Chair, Pam Bondi,
Attorney General,
Florida Office of Attorney General
Gerald Bailey,
Commissioner and Executive Director,
Florida Department of Law Enforcement
Elizabeth Dudek,
Secretary, Florida Agency for
Health Care Administration
Mike Carroll,
Interim Secretary,
Florida Department of Children and Families
John H. Armstrong, M.D., FACS,
State Surgeon General,
Florida Department of Health
Katherine Fernandez-Rundle,
State Attorney, Eleventh Judicial Circuit
(Miami-Dade)
Sheriff Wayne Ivey,
Brevard County Sheriff’s Office
Sheriff Ric L. Bradshaw,
Palm Beach County
Sheriff’s Office
Juan Jesus Santana,
Division Chief, Miami-Dade
Police Department
Michael DeLeo,
Chief of Police,
City of Tallahassee Police Department

Pursuant to Section 624.351, Fla. Stat., the Medicaid and Public Assistance Fraud Strike Force (Strike
Force) organized in March 2011. The first tasks the
Strike Force took on were reviews of the status of the
Medicaid and public assistance fraud systems and the anti-fraud resources in place.
Information provided by the Agency for Health Care
Administration and the Department of Children and
Families painted a picture of burgeoning caseloads of
Medicaid and public assistance beneficiaries, between
2007 and 2010. More significant, though, were the trends of increasing referrals to the Medicaid Fraud
Control Unit, within the Office of Attorney General, and the Division of Public Assistance Fraud, within the Department of Financial Services for fraud investigations.
The initial Strike Force inventories of the resources available to combat fraud indicated there were numerous processes and strategies already in place to do just that. However, in light of the evidence that fraudulent activity was increasing, the Strike
Force began to investigate different and innovative approaches.
The Strike Force organized working committees made up of representatives from member agencies who came together to share their concerns and ideas for possible enhancements that could improve the results of our fraud fighting efforts. The Strike Force also invited speakers to meetings who could share information on different facets of federal, state and local anti-fraud activities so that linkages could be identified where resources could be leveraged.
Some proposed enhancements were technological, like the potential that advanced detection systems offered. The value of organizational analyses, through business process mapping, was demonstrated by the
Department of Health as a way to identify points in processes where changes could enhance prevention, detection and recoupment. Other suggestions entailed
Strike Force Final Report i i considering ways to leverage existing resources together to produce results that far exceeded what any single resource could attain.
Over the years, these efforts produced numerous recommendations that were formally embraced by the Strike Force, many of which eventually came to fruition. The Strike Force placed primary emphasis on improving prevention efforts to escape the “pay and chase” approach that is systemically inherent in public assistance systems. In particular, Strike Force members noted that the systems needed to make better use of available data. It was also widely accepted that if prevention efforts were to be maximally effective, it was necessary to improve enforcement, investigative and prosecutorial strategies that could serve as deterrents.
Many recommendations proposed by the Strike Force have been or are being addressed. Here are some highlights of Strike Force recommendations that have been or are being implemented which hold great promise for reducing fraud in Florida’s Medicaid and public assistance systems.
• A new Department of Children and Families’
Customer Authentication System verifies the identity of applicants for assistance before public assistance is disbursed.
• The Department of Children and Families procured a new Electronic Benefit Transfer vendor system which incorporates automated anti-fraud analytics which can enhance detection of Electronic Benefit Transfer retail fraud.
• The Agency for Health Care Administration is procuring a new case management system to replace the existing legacy system with one that will include neural networking and other advanced techniques for detecting emerging fraud and abuse patterns.

• The Agency for Health Care Administration is also procuring a new Public Benefits Integrity
Data Analytics and Information Sharing
Initiative that will detect and deter fraud, waste and abuse in Medicaid and other public benefit programs.
• The Medicaid Fraud Control Unit has extended their federal authorization to engage in data mining and is seeking vendor services to provide technology with advanced data analytics that will greatly enhance the efficiency of those efforts.
• The leveraging of resources between federal, state and local law enforcement to collaborate on investigative operations and maximize charges against perpetrators of fraud is gaining momentum; local agencies like Manatee County
Sheriff ’s Office, Miami-Dade Police Department and Palm Beach County Sheriff ’s Office are establishing interagency models that can be replicated.
• Through its role as the State Law Enforcement
Bureau for the United States Department of
Agriculture Food and Nutrition Services, the Division of Public Assistance Fraud is continuing to build interagency partnerships around the state.
With regard to prosecutorial strategies, the Strike
Force learned that consequences can be maximized for persons trafficking in EBT benefits by prosecuting an offender for aggravated white collar crime. Currently, an EBT card meets the requirement of a credit card under Florida statute and credit card fraud is a predicate offense for aggravated white collar crime.
This is a practice which the Strike Force strongly supports as a deterrent.
One key to sustaining Strike Force momentum will be how effectively the Strike Force transitions its more vital functions to member agencies. It is hoped that this will be accomplished through an interagency work group that the Agency for Health
Care Administration has agreed to coordinate. This group will be the vehicle to pursue critical anti-fraud activities.
Four issues in particular stand out as critical to
Florida’s future anti-fraud efforts:
• Interagency cooperation and coordination,
• Aggressively pursuing enforcement and prosecution of identity theft,
• Continued build up of the use of large scale data analytics (“big data”), and
• Focusing on Medicaid Managed care fraud.
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In 2010, the Florida Legislature found “that there is a need to develop and implement a statewide strategy to coordinate state and local agencies, law enforcement entities, and investigative units in order to increase the effectiveness of programs and initiatives dealing with the prevention, detection, and prosecution of Medicaid and public assistance fraud,” Section 624.351(1), Fla. Stat. This finding was validated by documented trends in utilization that reflected an increasing need for Medicaid and public assistance services, as well as increases in referrals to government agencies for fraud investigations.
Between December 2007 and December 2010, requests for assistance submitted through the Automated
Community Connection to Economic Self Sufficiency
(ACCESS), at the Department of Children and
Families (DCF), increased by 33 percent. Caseloads for Supplemental Nutrition Assistance Program
(SNAP) benefits increased 118 percent and Temporary
Assistance for Needy Families (TANF) caseloads increased by forty percent. Along with increases in these caseloads, there was also an increase in referrals to the Division of Public Assistance Fraud (DPAF), the investigative unit within the Department of Financial
Services (DFS) dedicated to fraud detection in these public assistance programs and among Medicaid beneficiaries. Between December 2007 and December
2010, the number of referrals to DPAF increased by
35.6 percent, yet DPAF investigative resources had been reduced by 27.6 percent.
During the same time frame, the Agency for Health
Care Administration’s (AHCA’s) Medicaid caseload increased by 36.86 percent and AHCA referrals to the Medicaid Fraud Control Unit (MFCU) at the
Office of Attorney General (OAG) for Medicaid fraud investigations also increased.
There was clearly a need to take a more collaborative approach to addressing fraud in these public assistance programs. The Medicaid and Public
Assistance Fraud Strike Force (Strike Force), officially organized on February 25, 2011, was intended to fill that role.
Strike Force Final Report 1

2 Strike Force Final Report

Section 624.351(2), Fla. Stat., stated that the “Medicaid and Public
Assistance Fraud Strike Force is created within the department to oversee and coordinate state and local efforts to eliminate Medicaid and public assistance fraud and to recover state and federal funds.
The strike force shall serve in an advisory capacity and provide recommendations and policy alternatives to the Chief Financial
Officer.”
Recommendations submitted to the
Strike Force during its tenure can be found throughout this report in insets located near text describing the status of their implementation.
Areas specified for Medicaid and Public Assistance Fraud Strike Force guidance included:
1. Compiling an inventory of local, state and federal anti-fraud strategies;
2. Developing a plan for coordinating state and local resources to prevent Medicaid and public assistance fraud;
3. Identifying strategies to more efficiently use innovative technology and data sharing to better combat Medicaid and public assistance fraud;
4. Implementing a grant initiative for multiagency, state or local agencies to seed fraud prevention, detection, and investigation programs; and
5. Developing and promoting crime prevention services and educational programs that serve the public.
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When the Medicaid and Public Assistance Fraud
Strike Force (Strike Force) was launched in 2011, a number of resources were already in place in state and local agencies with the authority to detect, investigate and prosecute fraud in the Medicaid and public assistance service delivery systems. At the inaugural meeting of the Strike Force, agencies were asked to give a brief description of their agency and presentations regarding the Medicaid and public assistance programs were solicited. The status of their operations at the first meeting is provided below.
DEPARTMENT OF CHILDREN AND FAMILIES
The Department of Children and Families (DCF), as the home to Automated Community Connection to
Economic Self Sufficiency (ACCESS), is referred to as the “front end” of the Medicaid and public assistance programs. The ACCESS Program is the eligibility determination arm for food assistance, cash assistance and Medicaid. ACCESS determines eligibility for those programs collectively through one integrated application and eligibility depends on meeting the qualifying requirements of the respective programs.
In 2009, DCF reduced staffing in public assistance investigations (ACCESS Integrity) by forty percent for budgetary reasons. By 2011, DCF reported that approximately three million people were receiving food stamp assistance, 2.9 million (including
Supplemental Security Income eligible persons) people were receiving Medicaid, and 106,000 people were receiving cash assistance.
Mechanisms and processes were in place to prevent, detect and prosecute fraud including a link on DCF’s
ACCESS website which allowed the general public to report potential fraud concerns.
ACCESS received data exchanges from many other agencies and data sources, such as the Social Security
Administration, Agency for Workforce Innovation and the Internal Revenue Service. Data was evaluated by eligibility staff to confirm that information provided by applicants was accurate, and to determine on-going eligibility beyond the initial application.
DCF had a group of approximately 160 individuals who looked at the ongoing payments and distributions from public assistance programs and identified cases that needed further investigation. In 2010, approximately 70,000 such cases were identified. More detailed reviews of those cases involved investigating system overpayment, underpayment or potential fraud. If it appeared that an applicant received benefits improperly, a case was referred to DCF’s
Benefit Recovery Team. During the 2009-10 federal fiscal year, ACCESS staff referred 73,000 cases to the
Benefit Recovery Team; 30,000 of the cases identified money due back to the state. The value of those claims, whether caused by fraud or mistake, was $28 million. In 2010, DCF collected $17 million, of which,
$3.4 million was attributed to fraud.
If a case appeared to include actual fraud, and not simply a mistake, the case was referred to the Division of Public Assistance Fraud (DPAF) for investigation and possible prosecution. With or without prosecution, the Benefit Recovery Team worked to recoup money due, either through deductions from a current benefit, as a cash payment, through the
Treasury Offset Program, or through a contracted collection agency (when the person was no longer an
ACCESS customer).
AGENCY FOR HEALTH CARE ADMINISTRATION
The Agency for Health Care Administration (AHCA) is the state agency responsible for the state’s Medicaid program, the licensure of the state’s health care facilities, and the sharing of health care data through the Florida Center for Health Information and Policy
Analysis. There are approximately 100,000 Medicaid providers, 70,000 of which actively bill the program.
The Division of Health Quality Assurance (HQA) regulates forty types of health care service providers
Strike Force Final Report 5

through the licensure, certification or registration of more than 46,000 health care facilities and providers and over 80 managed care organizations from which
Medicaid recipients may receive services.
When the Strike Force first formed, AHCA had already established a multitude of processes to prevent and detect fraud and recoup overpayments which continue today. These were described in detail in
AHCA’s annual report, The State’s Efforts to Control
Fraud and Abuse FY 2009-10 and some are highlighted below.
Some strategies were intended to limit initial enrollment of providers:
• Enhanced criminal background screening of
Medicaid providers;
• Increased anti‐fraud reporting for licensed home health agencies;
• Clinical Laboratory regulation included review for both state and federal applications (carefully checking owner information, laboratory structures, addresses and directors for potential fraudulent clinical laboratory applications);
• Proof of financial ability was required for initial licensing of home health agencies, home medical equipment providers, health care clinics, nursing homes, hospitals and assisted living facilities; and
• Medicaid managed care was being piloted under a Medicaid waiver as a potentially valuable antifraud tool because Managed Care Organizations
(MCOs) are paid a monthly capitation rate and provided incentives and contractual obligations to prevent, identify and combat fraud and abuse, limiting the state’s exposure.
Other strategies were designed to address prevention, detection and recoupment activities dealing with providers at initial licensure or after registration as
Medicaid providers, as described here.
• Utilization management functions (including on-site and desk reviews of quality of care and claims monitoring for various provider types), prior authorization requirements for certain expenditures, smart purchasing and preferred drug policies were used to help prevent unnecessary, excessive, duplicative or otherwise inappropriate expenditures in the Medicaid fee‐ for‐service program.
6 Strike Force Final Report
• AHCA’s Office of Inspector General (OIG)
- comprised of the Office of Medicaid
Program Integrity (MPI), Internal Audit and the Investigations Unit - is responsible for coordinating and improving AHCA’s overall
Medicaid program integrity efforts. The AHCA
OIG also established and leads the Fraud
Steering Committee within AHCA to ensure compliance with Senate Bill (SB) 1986, to prevent and detect fraud and abuse.
» MPI reviews the billing and claims activities of Medicaid recipients and providers to minimize fraudulent activities and program abuses, while also identifying neglect of recipients. MPI recovers millions in
Medicaid overpayments each year and imposes sanctions, as appropriate. The unit employs analytical detection tools and fraud and abuse prevention activities. They also conduct audits and make referrals to the Medicaid Fraud Control Unit (MFCU), the Department of Health (DOH) and other regulatory and investigative agencies when appropriate.
» AHCA routinely tracked provider types associated with fraudulent practices. All cases opened within MPI and MFCU include a primary provider type. Tracking enables both offices to focus resources on providers for whom the most fraud or potential fraud is detected.
Strike Force Recommendation: There is a need to identify the providers among whom the most fraud is detected in the Medicaid system so that enforcement efforts are targeted to the more frequent offenders.
• AHCA successfully collaborated with external partners, stakeholders and internal bureaus and offices to coordinate the prevention of fraud and abuse of the Medicaid program. Most of this collaboration was accomplished through workgroups such as the Interagency Anti‐Fraud
Working Group (coordinated by AHCA and meeting bimonthly), biweekly meetings with
MFCU to discuss potential referrals, and regular teleconferences with MPI staff from other states including New York, California and Texas
(similar Medicaid population states) to discuss fraud and abuse detection activities and to share and learn from each other.

• The Division of Operations’ Third Party
Liability Unit was also successful in taking actions to identify and recover millions in
Medicaid funds expended for claims paid by
Medicaid for which a third party was actually, or eventually, liable.
• The Medicaid claims processing system contained front end edits to prevent payments that could be considered abusive practices, using a proactive cost avoidance philosophy.
» Opportunities were taken to educate providers to proactively address noncompliance issues that resulted from inadvertent errors as well as misunderstandings or lack of understanding about program policies.
• The HQA Field Operations staff participate in
“Operation Spot Check” visits sponsored by
MFCU with multiagency involvement. Visits identify issues for regulatory action or referral to other appropriate agencies/departments.
Senate Bill 1986.
AHCA undertook a number of activities intended to implement the 2009 SB 1986
(Section 31 of Chapter 2009-223, Laws of Florida).
The major elements of this bill were designed to prevent fraudulent or criminal providers from entering the system and enhancing penalties for those who perpetuate fraud. Some specific areas that AHCA addressed are described further here.
AHCA completed a Strategic Plan for Data
Connectivity: Health Care Fraud Databases in
December 2010. AHCA designed the plan to be a dynamic document that could be adjusted to meet the needs of an ever changing Medicaid system and serve as a roadmap for facilitating the electronic exchange of health information used to identify and prevent fraud and abuse in the Medicaid program.
AHCA increased their focus and efforts on fraud in the Medicaid Developmental Disabilities Waiver
(DD Waiver) programs. AHCA’s Inspector General,
MPI, MFCU and the Agency for Persons with
Disabilities’ (APD’s) Inspector General all increased their communication and cooperation against DD
Waiver fraud. The APD Inspector General hosted quarterly DD Waiver Fraud Working Group meetings attended by all of the above agencies, along with the
Department of Elder Affairs and DCF. The increase in communication and teamwork produced criminal and administrative investigations and increased programmatic support for anti‐fraud activities. This inter‐agency cooperation led to changes in policies and procedures that improved investigative speed and effectiveness.
As a result of anti‐fraud and abuse provisions included in SB 1986, AHCA contracted with a vendor, Sandata
Technologies, LLC, to implement the Telephonic
Home Health Service Delivery Monitoring and
Verification (DMV) Program. Using the Santrax Payor
Management (SPM) system, the vendor addressed aberrant billing practices, potential fraud and the quality of recipient care in Medicaid home health care.
The contract was signed April 8, 2010, and the DMV project was successfully launched on July 1, 2010.
The goal of the project was to ensure that home health nurses and aides actually went to the homes of the recipients that had been prior authorized to receive home health visits to provide the services outlined in the recipients’ plans of care and ensure that home health service providers received reimbursement only for services actually provided. Medicaid reimbursable home health visits provided by registered nurses, licensed practical nurses and home health aides were scheduled, verified and tracked through Sandata’s
SPM system.
Also as a result of provisions included in SB 1986,
AHCA amended an existing contract with KePRO
- responsible for utilization management for home health visits, private duty nursing, personal care services and inpatient medical and surgical services - in FY 2009‐2010 to include a Comprehensive On‐Site
Care Management Project in Miami‐Dade County for home health visits. The purpose of this pilot project was to identify potential overutilization and fraud or abuse of Medicaid services by ensuring that the level of provided services matched the needs of the recipients.
DEPARTMENT OF HEALTH
The mission of the Department of Health (DOH) is to protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
DOH is a critical partner in the fight against Medicaid fraud because their Medical Quality Assurance (MQA) bureau licenses about a million licensees/practitioners in forty different professional groups in Florida, though not all licensees are Medicaid providers.
Strike Force Final Report 7

In a 2010 report, AHCA indicated that DOH was working in partnership with AHCA and MFCU to ensure that licensees convicted of fraud or terminated from the Medicaid program are dealt with appropriately under the terms set forth by law. The three agencies established a formalized notification system to inform the appropriate office of licensure actions, Medicaid overpayments, fraud convictions, and any other adverse actions against a health care practitioner’s license so timely action can occur.
AHCA was also sharing electronic Final Orders with DOH to identify sanctions and terminations of Medicaid providers so DOH could pursue action against the practitioner’s license. This permitted
DOH’s increased authority for licensure denial and disciplinary actions (provided by SB 1986) to be accomplished promptly against health care practitioners terminated from the Medicare and
Medicaid programs or convicted of felony and misdemeanor fraud crimes involving health care.
DOH was also collaborating with AHCA to implement
SB 1986 through enhanced information sharing. DOH was transferring data nightly to AHCA to identify practitioners who did not have an active DOH license and who could potentially still be billing Medicaid.
The DOH Director for MQA was meeting regularly with directors and senior managers of the AHCA OIG, the AHCA Division of Medicaid, the AHCA Division of HQA and MFCU to coordinate participation in joint projects, investigations and enforcement strategies.
This included regularly briefing the AHCA Secretary on the nature and progress of these collaborative efforts.
MQA enforcement managers were meeting regularly with managers and investigators from MPI to coordinate referral of complaints to DOH, as well as to plan and organize participation in joint investigative projects. If there is a violation of law by a Medicaid provider that is also a licensee of DOH, DOH conducts an investigation and reports back to the specific
Board for the designated discipline of the licensee.
Upon a determination of fraud or abuse by a licensee/ practitioner under contract with AHCA, DOH initiates action against the offending licensee/practitioner’s license. In 2010, a total of 109 legally sufficient referrals were received by DOH. After investigation by
DOH, no practice act violation was found in eighteen cases, a letter of guidance was issued in one case, a notice of noncompliance was issued in fifty cases, and forty cases were still pending at the end of the year.
In addition, the DOH Miami Investigative Services
Unit (ISU) coordinated with MFCU during the initial investigations of nine speech language pathologists and speech language pathologist assistants where there was an allegation of fraud. These resulted in nine arrests. The Chief of MQA/ISU was meeting biweekly with senior officers of MFCU to review current cases, coordinate investigative efforts and analyze trends in health care fraud.
Several ISU offices participated in “Operation
Spot Check” along with MFCU, AHCA, the Long
Term Care Ombudsman, local law enforcement and the State Attorney’s Office. These multi‐agency unannounced visits were made to assisted living and long term care facilities in an effort to identify
Medicaid fraud, practitioner standard of care violations, patient safety issues, elder abuse and code violations.
DOH Bureau of Vital Statistics coordinated with and supported the MPI/MFCU Dead Doctor Project. By providing electronic sharing of DOH vital statistics information, AHCA was able to promptly terminate
Medicaid providers that were deceased and eliminate the potential fraudulent use of provider numbers to bill the Medicaid program.
Specific initiatives in 2010 included an increase in the number of reciprocal training opportunities to advance a better understanding of the mission, authority and scope of respective programs. MFCU field investigators attended and participated in the DOH/MQA Regional Investigator training in
Miami in September 2009 and in Tampa in October
2009. The MQA/ISU Chief conducted DOH/MQA enforcement program presentations at two successive
MFCU Basic Training Classes at Pat Thomas
Law Enforcement Academy. In return, an MFCU
Investigator provided a program presentation for the
MQA/ISU Regional Training held in St. Augustine.
OFFICE OF ATTORNEY GENERAL
The Medicaid Fraud Control Unit (MFCU), within the
Office of the Attorney General (OAG), is the referral point for AHCA when provider cases are determined to entail fraud. MFCU is responsible for investigating and prosecuting providers who intentionally defraud the Medicaid program.
MFCU in Florida, started in 1982, was statutorily mandated and certified by the United States
Department of Health and Human Services (HHS).
MFCU was transferred from the Auditor General’s
Office to OAG in 1994.
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At the time the Strike Force formed, MFCU had 162 full-time employees, and was primarily funded by a grant from the HHS OIG, which oversees MFCUs with respect to federal financial participation. The state provided match for that grant.
MFCU had three regions; the northern region headquartered in Tallahassee, which also served as statewide headquarters; the central region, headquartered in Tampa; and the southern region headquartered in Miami. MFCU also had eight field offices across the state.
During FY 2009-2010, MFCU looked into 1,838 complaints. Fraud was alleged in 981 and 857 were made for patient abuse, neglect and exploitation. Of those complaints, MFCU opened 388 cases and closed
383. Cases opened involved home and community based waiver services (a variety of in-home care services), pharmaceutical manufacturers ( qui tam cases), physicians, Durable Medical Equipment
(DME) providers and community behavioral health providers. In 2010, MFCU recovered $144 million.
The bulk of the recovery was from qui tam cases, filed in federal court containing allegations that the Florida
False Claims Act had been violated. The Complex
Civil Enforcement Bureau (CCEB) is a section within
MFCU which investigates and litigates cases that allege violations of the Act when the false claims were submitted to the Florida Medicaid Program. Qui tam cases are typically cases against pharmaceutical companies for manipulating drug pricing, which cause false claims to be filed for the payment of pharmaceutical products. CCEB evaluates qui tam complaints and prioritizes them according to their underlying merit and value to the state.
In addition, CCEB expanded MFCU’s role among the multi-state working groups litigating Medicaid fraud issues.
One challenge MFCU had, prior to 2011, was utilizing access to Medicaid claims data to generate leads for investigations. MFCU operates on a budget that includes federal grant funds and related grant restrictions did not allow MFCU to engage in data mining - the practice of electronically sorting
Medicaid Management Information Systems claims through statistical models and intelligent technologies to uncover patterns and relationships and identify aberrant utilization and billing practices that are potentially fraudulent.
The rationale for this restriction was that AHCA was already receiving federal funds to conduct data mining and the federal government did not want to pay for duplicative efforts. Since the initial enactment of the restriction, however, processes have become more automated and there have been huge advances in computer hardware, software and the ability to manage data. In addition, MFCUs had developed the capability to undertake such tasks effectively.
The Florida MFCU, in collaboration with AHCA, requested that the Center for Medicare and Medicaid
Services (CMS) grant a waiver of the grant restriction.
The objective was to supplement AHCA’s data mining activities. CMS granted the waiver request as a three year pilot project that began October 1, 2010. Florida was the only state that was granted such a waiver.
During the first year of the project, three Medicaid
Fraud Analysts devoted up to fifteen percent of their time to the project.
DEPARTMENT OF FINANCIAL SERVICES
The Division of Public Assistance Fraud (DPAF), within the Department of Financial Services (DFS), is responsible for safeguarding the public and businesses in Florida against acts of public assistance fraud and the resulting impact those crimes have by enforcing state criminal laws in relation to eligibility for and proper use of public assistance. DPAF is the referral point for DCF when actual fraud is suspected of an applicant for or recipient of public assistance services.
When the Strike Force first formed, DPAF had 63 staff members statewide, in ten locations. They relied on data sharing agreements with a number of different agencies in order to access information on wages, child support, driver’s licenses, vehicle registrations, deceased persons, prison and jail inmates and retirement income to assist in their investigations.
If DPAF compiles sufficient evidence to constitute a criminal case, it is referred to the State Attorney for prosecution. Cases that are not prosecuted are referred back to DCF for administrative program disqualification of the violator and for recoupment of improperly-issued benefits occurring from a participant’s program violation.
In 2010, DPAF received 33,000 referrals. About 5,900 were flagged for investigation. Due to insufficient manpower, only 2,912 were investigated.
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Approximately twenty years ago, the United States
Department of Agriculture (USDA) designated DPAF as the State Law Enforcement Bureau (SLEB) for
Electronic Benefit Transfer (EBT) cards in Florida.
In that role, they serve as the liaison between local and state agencies and USDA in carrying out targeted investigations of electronic Supplemental Nutrition
Assistance Program (SNAP) benefit trafficking.
DPAF supports the investigations by obtaining and managing funding of EBT cards that can be used in undercover buys by investigative units. DPAF works with local law enforcement agencies to ensure that targeted retail establishments are cleared for investigative units to enter undercover and gather the necessary evidence to create a case of SNAP fraud against the retail operator. DPAF also provides technical assistance to law enforcement, regulatory and prosecutorial agencies in the pursuit of criminal prosecutions. DPAF then follows up with USDA to provide the information necessary to disqualify the violating retailer from further participation in the SNAP program and conducts investigations of recipient fraud that may have contributed to the retailer fraud.
DEPARTMENT OF LAW ENFORCEMENT
The Florida Department of Law Enforcement (FDLE) is a statewide law enforcement agency comprised of investigators and crime laboratory analysts who operate through regional operation centers, which are located in seven major metropolitan areas. FDLE also provides infrastructure support, data bases and other systems to other agencies which conduct investigations around the state. FDLE routinely works with DFS and the OAG on a variety of fraud issues.
FDLE’s investigative focus is dedicated to multijurisdictional, organized criminal groups involved primarily in economic, major drugs, violent and public integrity criminal violations. In instances where public assistance programs are either targeted or an instrumentality of fraudulent activities and the crimes are perpetrated by organized criminal groups,
FDLE will investigate these activities.
LOCAL LAW ENFORCEMENT
Local law enforcement agencies reported varying degrees of involvement in investigating public assistance fraud when the Strike Force first formed.
The Palm Beach County Sheriff ’s Office (PBSO) had a full-time Public Assistance Fraud Unit and had been involved with numerous investigations. The
10 Strike Force Final Report
Sheriff ’s office had worked with the FDLE on food stamp investigations and investigated housing fraud, mortgage fraud and embezzlement. The State Attorney in Palm Beach County was also willing to participate in prosecutions of Medicaid fraud.
The Hillsborough County Sheriff ’s Office had a
Major who handled investigation of Personal Injury
Protection fraud and fraud relating to pain clinics.
Cases were referred to them from a variety of sources, including jails, and often involved inmate fraud.
The Miami-Dade Police Department (MDPD) did not have a unit dedicated to Medicaid investigations.
However, they had participated in investigations conducted by task forces where efforts were concentrated on health care related criminal conduct.
MDPD had investigated complaints concerning
DME companies, which were flourishing in South
Dade. Many of MDPD’s investigations led to the discovery that the DME companies were actually money laundering organizations paid by Medicaid and
Medicare for services that were not performed. MDPD had successfully investigated some of those cases but, as with other law enforcement agencies, limited resources prevented them from concentrating their efforts on these issues.
In Miami-Dade, prosecution of Medicaid and public assistance fraud cases were handled by the
State Attorney’s Economic Crimes Unit. The State
Attorney’s Office developed a model for prosecution of insurance fraud. This model was replicated for
Workers’ Compensation fraud cases. While no cases had been presented involving Medicaid fraud, the model could be replicated for Medicaid and public assistance fraud.

The Medicaid and Public Assistance Fraud Strike
Force (Strike Force) continued its census of other fraud fighting initiatives through presentations at Strike Force meetings. After one full year of operations, one recommendation to the Strike Force was that front line staff, in particular, be asked to offer up suggestions and information that can improve efforts to eliminate Medicaid and public assistance fraud. The anti-fraud strategies and initiatives that were presented to the Strike Force are summarized below.
LINK ANALYSIS
Link analysis is a data matching technique used to identify relationships between entities. It has been used by organizations for the investigation of criminal activity, fraud detection and the development of actionable intelligence. Through link analysis, relationships may be identified among various types of entities or objects, including organizations, people and transactions. In combating Medicaid and public assistance fraud, link analysis is used for three primary purposes: 1) to find matches in data for known behavior patterns of interest; 2) to delineate anomalies where known patterns are violated; and 3) to discover new patterns of interest (through social network analysis and data mining).
In 2011, the Agency for Health Care Administration
(AHCA) piloted the use of link analyses of individuals and groups found in their provider databases. Match and link technologies were used to gather information from the following sources that could be related to provider entities:
• Federal List of Excluded Individuals and
Entities;
• Other states’ Medicaid exclusion lists;
• The Department of Health (DOH) adverse actions and previous terminations;
• Other criminal databases;
• Florida Corporate records;
• Medicaid prescribing database;
• Florida Medicaid Management Information
System (FMMIS) ownership records;
• National Provider Identifier records (National
Provider and Plan Enumeration System);
• Tax records;
• Property records; and
• Familial and social records.
Strike Force Recommendation: Incorporate routine reports to the Strike Force members of suggestions and feedback from the front line staff on how to improve our interagency efforts to eliminate Medicaid and public assistance fraud and recover state and federal funds.
Potential relationships with excluded/criminal entities were identified for Medicaid providers using different parts of their names, abbreviations, addresses, and other identifying elements. These linking technologies were used to uncover providers reporting false identity information to avoid exclusion matching and to reveal non-disclosed owners, directors and officers of companies; violators using their immediate relatives to reopen new companies or continue existing companies often at the same business address; people using their partners to continue doing business or open related businesses; people using multiple electronic funds transfer accounts; and prescribing or referring services (Part D, Labs, and Durable Medical
Equipment) in states which either do not require such entities to be enrolled for these referrals or do not check valid referral national provider identifiers on claims.
Strike Force Final Report 11

From July 2011 through September 2011, 120 providers were identified and actions taken which involved one or more of the following:
• Termination from the program;
• Denial of prescriptions written by the provider;
• Placement on pre-payment review;
• Referrals to Medicaid Managed Care
Organizations (MCOs);
• Referrals to field staff; and/or
• Potential sanctions and fines.
BUSINESS PROCESS MAPPING
Business process mapping (mapping) refers to defining the activities of a business entity, who is responsible for the activities, the processes used to complete the activities and how the success of each process is determined. Once mapping is complete, the requirements of every internal business process have been documented. The first step in gaining control over an organization’s performance is to know and understand the basic business processes.
Emergency Suspension Orders.
As an outgrowth of the provisions of the 2009 Senate Bill (SB) 1986 that provided AHCA increased authority over termination of previously convicted providers from the Medicaid program, DOH undertook an initiative to map the processes involved in issuing an
Emergency Suspension Order (ESO). Enhancing this process could provide more timely actions against practitioners who have been accused of committing health care fraud. This mapping began on May 5,
2011, and an initial map was completed by May 31,
2011. DOH used the activity of mapping to define current processes and identify where they could be improved. After the initial mapping to define improved processes, DOH identified and incorporated additional improvements into the process for issuing
ESOs.
MULTI-JURISDICTIONAL PARTNERING
Multi-jurisdictional partnerships are not new in the field of law enforcement. However, the Strike Force learned that these partnerships are also being used to fight public assistance fraud.
Palm Beach County Sheriff ’s Office.
Since 2008, the
Palm Beach County Sheriff ’s Office (PBSO) worked with the United States Department of Housing and
12 Strike Force Final Report
Urban Development (HUD) to identify perpetrators of housing fraud and uncover housing fraud schemes in public housing sites in Palm Beach County. The objective of these efforts was to decrease housing fraud, ensuring that public housing was available to those who are truly needy. The initiative entailed identifying individuals who falsified their public housing application. PBSO also took advantage of opportunities to increase awareness among the public that cases would be investigated, perpetrators would be arrested and restitution would be sought.
In 2009, a joint investigative team was established in collaboration with the State Attorney’s Office for the
Fifteenth Judicial Circuit, HUD’s Office of Inspector
General (OIG), and the United States Department of
Agriculture’s (USDA’s) OIG to investigate criminal activity relating to federal or state funded public assistance.
By 2011, the investigative group had expanded to include the Inspectors General for the United States
Department of Health and Human Services (HHS) and the Social Security Administration, as well as many public housing authorities and providers.
Through the collaboration with these agencies, numerous public assistance fraud investigations were conducted including housing assistance, SNAP
Electronic Benefit Transfer (EBT) fraud (trafficking),
Medicaid fraud and other federal and state welfare programs.
Through PBSO investigations they learned that perpetrators of public assistance fraud do not just defraud one program; they typically defraud several programs simultaneously. When a case comes to
PBSO’s attention that involves an individual who is determined to be receiving public assistance, PBSO contacts other agencies that may be involved with the suspect to determine if they also have an interest in that person as a public assistance beneficiary. As a result of these collaborations to build cases, they achieved a 98 percent conviction rate in those public assistance fraud cases. The most important facet of these collaborations was enabling PBSO to find career criminals who are engaged in other illegal activities, such as organized crime or public corruption. In 2011, over 100 public assistance recipients were arrested for fraud and more than $2,000,000 was ordered in restitution by the courts.

Operations Meal Ticket I and II.
The Manatee
County Sheriff ’s Office (MCSO) was first introduced to EBT retail fraud when the USDA OIG and the
United States Department of Homeland Security
(DHS) asked MCSO to assist in a federal investigation of a convenience store. USDA had identified a small convenience store that had the highest volume of
EBT transactions in the county. They were processing
$35,000 to $45,000 in EBT transactions per month which is about the same as a large grocery store.
MCSO conducted undercover operations for over a year where they would make small purchases and ask for cash back. The clerk would then charge $200 on the card, keep $100 and give the undercover agent the change. Once MCSO developed sufficient probable cause, they obtained search warrants for the store and the owners’ houses. Ultimately, they seized about
$360,000 and a Cadillac Escalade. In addition, the defendants were ordered to pay another $2.6 million in restitution. All three owners were brothers and were sentenced to a total of 85 months in federal prison.
After that investigation concluded, the involved
MCSO personnel returned to the primary focus of their unit, narcotics investigations, in which they would uncover stacks of EBT cards as they executed drug search warrants. Eventually, MCSO determined that in some instances the EBT cards were being exchanged for drugs; in other cases, they were simply being purchased. This launched Operation Meal
Ticket I, which was conducted between November
2011 and May 2012.
The focus of this operation was retail establishments and purchasers of EBT cards. The operation involved
MCSO, the Bradenton Police Department, USDA OIG,
DHS and the Division of Public Assistance Fraud
(DPAF). DPAF supplied the EBT cards to be used for the operation and helped MCSO navigate the system.
Seventy-two separate transactions were conducted as part of the investigation. This operation resulted in 78 felony and two misdemeanor charges and arrest warrants on 55 individual defendants. MCSO also served three search warrants on a few retail establishments; one led to an additional charge for worker’s compensation fraud.
After Operation Meal Ticket I concluded,
Operation Meal Ticket II was launched as a twopart investigation. Part I centered on a local pizza restaurant. The owner owned two restaurants in
Manatee and one in Sarasota County. MCSO had intelligence that the owner was buying EBT cards for fifty cents on the dollar from people coming to the restaurant. He would then take the cards to a buyer’s club to buy restaurant supplies. The owner’s prior twenty months of buyer’s club records were subpoenaed which indicated the owner had used
53 different EBT cards a total of 131 times totaling
$23,734.46. DPAF identified the cardholders and the restaurant owner acknowledged that he had bought the cards. Arrest warrants were issued and served on those cardholders and the restaurant owner. The pizza restaurant investigation resulted in a total of 49 different defendants.
For the second part of this investigation, MCSO wanted to target cardholders that were trafficking their cards. During this investigation, a total of 64 separate transactions were made, with 44 defendants involved. This resulted in 123 arrest warrants against
103 defendants. Most of the individuals selling the
EBT cards were the card owners, but some did not know that an acquaintance had used their card; that information was used to arrest the person who had fraudulently used the card.
UNITED STATES DEPARTMENT OF
HEALTH AND HUMAN SERVICES OFFICE
OF INSPECTOR GENERAL
Since its 1976 establishment, the Office of Inspector
General of HHS has been at the forefront of the nation’s efforts to fight waste, fraud, and abuse in
Medicare, Medicaid and more than 300 other HHS programs. HHS OIG is the largest inspector general’s office in the federal government, with approximately
1,600 staff dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs. A majority of OIG’s resources goes to the oversight of Medicare and Medicaid — programs that represent a significant part of the federal budget and that affect this country’s most vulnerable citizens.
The Office of Audit Services (OAS) conducts independent audits of HHS programs and/or HHS grantees and contractors, including state Medicaid agencies. These audits examine the performance of
HHS programs and/or grantees in carrying out their responsibilities and provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.
OAS conducts audits using its own resources and also oversees audit work performed by others. OAS is the largest civilian audit agency in the federal
Strike Force Final Report 13

government. OAS conducts its work in accordance with Government Auditing Standards issued by the
Comptroller General of the United States; the Single
Audit Act Amendments of 1996; applicable Office of
Management and Budget circulars; and other legal, regulatory, and administrative requirements. HHS
OIG plays an important role in identifying waste and abuse in the Medicaid program. They conduct audits which focus on processes employed by Medicaid agencies and also investigate allegations of fraud.
In follow up to these audits, the subject of the audit is provided with constructive feedback to assist them in improving their processes to mitigate waste, fraud and abuse in their programs.
The Office of Investigations (OI) conducts criminal, civil and administrative investigations of fraud and misconduct related to HHS programs, operations and beneficiaries. State-of-the-art tools and technology assist OIG investigators around the country and help
OI meet its goal of becoming the world’s premier health care law enforcement agency.
As a point of interest, the HHS OI reported that
2011 was one of the biggest years with regard to investigations and Florida represented about twenty percent of the criminal cases prosecuted. The
Federal Middle and Southern Districts of Florida received the lion’s share of qui tam cases (civil relator lawsuits) filed. These qui tam cases were handled in cooperation with the MFCU.
HEALTH CARE FRAUD PREVENTION AND
ENFORCEMENT ACTION TEAMS
Health Care Fraud Prevention and Enforcement
Action Teams (HEAT) are a joint initiative, announced in May 2009 between HHS and the
Department of Justice which work in cooperation with the MFCUs targeting Medicare and Medicaid fraud.
Two of the nine national HEAT teams are located in
Florida. In these locations, federal agencies join forces with state and local law enforcement to leverage their efforts to fight health care fraud. By 2012, HEAT operations in nine locations had charged more than
1,330 defendants who collectively falsely billed the
Medicare program for more than $4 billion.
OFFICE OF INSURANCE REGULATION
The Office of Insurance Regulation (OIR) plays an important role in regulating and monitoring Health
Maintenance Organizations (HMOs), or MCOs. OIR licenses HMOs after conducting criminal background checks and ensuring financial solvency. OIR then continues to monitor their finances periodically.
In order to become licensed, HMOs must present a sound business plan, financial statements that reflect solvency, a feasibility study that reflects the potential for success of the business plan, a contingency plan in the event that the business plan cannot be fully implemented and a listing of all officers for the organization. Following licensure, OIR continues to monitor the financial health of HMOs through the review of financial statements, audited financial statements, actuarial statements and trends in medical loss and administrative expense ratios. In 2012, there were forty HMOs operating in Florida, with eighteen of them authorized by AHCA to provide Medicaid services. HMO members included 1.1 million
Medicaid subscribers and an additional 1.1 million are expected to be added as Florida moves to statewide managed care. As of May 2014, nearly three million
Medicaid recipients are participating in managed care plans.
MEDICAID MANAGED CARE OVERSIGHT
Within AHCA, several bureaus are involved in monitoring managed care providers. Monitoring is conducted through annual on-site inspections and contract reviews, as well as quarterly desk audits/ reviews. Monitoring efforts look at medical records, reporting of fraud and abuse, complaints and grievances filed, as well as performance measures that profile the health status of enrolled members and provision of services. Quality of services is evaluated based upon coordination of care, utilization management, maintenance of records and administration practices. Contract compliance considers member eligibility, enrollments and disenrollments, services provided, member rights and community outreach. In addition, provider credentialing and recredentialling, provider services, provider contracts and subcontracts, and covered services are all reviewed.
14 Strike Force Final Report

MANAGED CARE ANTI-FRAUD STRATEGIES
In 2012, at the direction of the members, Strike Force staff prepared and distributed a survey to key states with experience in statewide Medicaid managed care. This was done to identify strategies to address fraud as Florida transitioned from fee-for-services to statewide managed care in Medicaid. Responses were received from Tennessee, Georgia and Arizona.
Notable findings included:
• All three states require all providers in an
MCO to register with the Medicaid agency as a
Medicaid provider.
• In Arizona, MCOs are not permitted to conduct investigations of suspected fraud.
• In Arizona, a member fraud unit in the OIG investigates suspected fraud by MCO members.
In addition, AHCA staff reviewed information available through the Center for Medicare and
Medicaid Services (CMS) to evaluate how Florida’s existing anti-fraud strategies compared to other states’ strategies. Overall, a review of the activities that are used by other states as program integrity strategies for managed care indicated that AHCA already uses these same strategies. In addition, in Florida the MCOs are responsible for the following:
• MCOs must report internal or external suspected or confirmed fraud/abuse within fifteen days of discovery;
• MCOs must report progression of anti-fraud casework on a quarterly basis into a web-based reporting system that enables the Office of
Medicaid Program Integrity (MPI) to track all suspected fraud statewide; and
• MCOs must submit a fraud and abuse activity report on overpayments and recoupments to
MPI.
EBT TRAFFICKING
PROSECUTORIAL STRATEGIES
Florida Statutes provide ample opportunity to secure substantial sentences against individuals engaged in EBT trafficking. Under Section 817.58(4), Fla.
Stat., “Credit card” means any instrument or device, whether known as a credit card, credit plate, bank service card, banking card, check guarantee card,
EBT card, or debit card or by any other name, issued with or without fee by an issuer for the use of the cardholder in obtaining money, goods, services, or anything else of value on credit or for use in an automated banking device to obtain any of the services offered through the device. Each instance of fraudulent EBT card use counts as one credit card offense.
This is helpful in prosecuting on a charge of aggravated white collar crime under Section 775.0844,
Fla. Stat. The statute requires the following elements to support a charge of aggravated white collar crime:
• One or more predicate offenses (which include credit card fraud, theft and other types of fraud, but does not include food stamp fraud);
• Two related crimes with similar intent, victim, or method;
• Ten or more elderly victims, twenty or more total victims OR a State agency or subdivision as the victim; and
• $50,000 or more was obtained fraudulently or an attempt was made to do so.
Section 775.0844, Fla. Stat., is a useful statute for prosecuting retailers engaged in EBT trafficking because the retailers that engage in this do it repeatedly; it is not difficult for them to accumulate the $50,000 in fraud, and it is easy to prove by going through their transaction records. When those elements are all present the offense is a first degree felony and it can be argued that it is also a sentencing level 9 offense. Under the aggravated white collar crime statute a mandatory prison sentence is required, unless the judge can find grounds for a downward departure. With the predicate crimes required for the white collar crime statute, it is difficult to find such grounds. In addition, there is a case from the
3rd District Court of Appeals that found that the aggravated white collar crime is a separate sentence from the predicate crimes, much like for racketeering.
So there is no reason not to charge the aggravated white collar crime along with each of the underlying crimes to increase the potential sentence.
Florida’s anti-racketeering law, Section 895.03,
Fla. Stat., is also a statute to use against EBT retail fraud. It allows for bringing in the card holders for their criminal offenses in relationship to the retail establishment. However, to prosecute under this statute there is a requirement for an “enterprise” - an ongoing organization, formal or informal, that both functions as a continuing unit and has a common purpose of engaging in a course of conduct. Using
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this statute is typically reserved for more prolific offenders. However, it is fairly easy to identify the card holders from the EBT transaction records.
An advantage of charging under the racketeering statute is that the offenders are more willing to cooperate and provide truthful testimony in the prosecution of the case when they realize they are engaged in a pattern of racketeering activity. In addition, under the racketeering statute, the jury is allowed to construe from testimony presented; it is not necessary to have someone from inside the organization testify. In an EBT fraud situation, the jury can construe from evidence that the person entered a store, the entire value of their EBT card was drained, yet they left the store empty handed. It is therefore reasonable to presume that the person used the card fraudulently. One problem with the racketeering charge is that the judge and jury may have an expectation that this type of crime involves a mob or gang. In addition, racketeering is only a sentencing level 8 offense.
How EBT crimes are charged is at the discretion of the State Attorney. Although it is possible to prosecute under the aggravated white collar crime and the racketeering statutes, there are complications in sentencing because there is some overlap. It is better for the prosecutor to decide ahead of time how they plan to prosecute. Where there are a number of store personnel or owners involved, a racketeering charge is better suited. Prosecuting one primary retailer would lend itself more toward a charge of aggravated white collar crime. With either charge there will be some money laundering charges involved because once the trafficker gets the money it has to go somewhere.
There are two available approaches to prosecuting on the money laundering. Section 896.101, Fla. Stat., addresses simply moving the money. Section 896.104,
Fla. Stat., addresses structured money laundering in which the amount moved is broken down into $10,000 increments to avoid the reporting requirements of financial institutions. Unless there are large amounts of money involved, it is easier to prosecute under
Section 896.101, Fla. Stat. This statute requires that you prove that the money moved was a result of criminal activity. Typically, that is difficult; but with the EBT cards, transaction records are sufficient evidence that the money was a result of criminal activity. Case law establishes that each instance of moving funds is a separate offense. This is very helpful in achieving substantial sentences.
A new statute went into effect on October 1, 2013, that can also be of great help in fraud prosecutions.
Section 817.5685, Fla. Stat., now makes it illegal to possess someone else’s identifying information without permission. This is now a predicate crime for aggravated white collar crime or racketeering.
Possession of identifying information for four different individuals is a misdemeanor and for five or more is a felony. When a person is in possession of identifying information on five or more individuals the statute presumes that it is possessed without permission. This is advantageous because sometimes it is difficult to locate the person who is the owner of the identity. In addition, at search warrant time in an EBT trafficking investigation, the store owners typically have numerous identification cards and
Personal Identification Numbers.
FRAUD FIGHTING TECHNOLOGY
The Department of Economic Opportunity (DEO) has learned that, with the proliferation of identity theft, people are accessing Florida agencies’ legacy systems to gather information on other people and then using it to commit fraud at the federal level (e.g., filing fraudulent tax returns). Some strategies used by DEO that other agencies can employ to help prevent this include:
• “Blurring” data so that it cannot be read by someone with unauthorized access.
• Using endpoint detection to find out where someone is who is accessing an information system using sniffers to find the originating server when someone tries to use a proxy server.
• Logging Internet Protocol (IP) addresses and blocking access for addresses when incoming information that has been involved in fraud or attempted fraud is detected.
• Using technology to geolocate people.
• Using analytic algorithms, putting together social media profiles and social footprint analysis and analyzing it with other data, so it can be determined where people should be, where they are and from where they are accessing information systems.
• Sharing information on perpetrators of unauthorized access so that other agencies can also block inappropriate access to data systems.
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Many changes have taken place during the tenure of the Medicaid and Public Assistance Fraud Strike Force
(Strike Force) that have positioned Florida to be more aggressive in fighting Medicaid and public assistance fraud. Some of these built on capabilities already in place and others looked to build on ideas gathered from other sources. Many of these were reported to the Strike Force at committee or full Strike Force meetings. This section of the report is dedicated to summarizing those with the greatest potential to have an impact.
DEPARTMENT OF CHILDREN AND FAMILIES
Office of Public Benefits Integrity.
In recognition of the importance of fighting fraud in public assistance programs, the Secretary of the Department of Children and Families (DCF) created a new organizational structure in 2011 intended to focus on fraud and abuse in the eligibility process. The functions of auditing for data integrity and benefit recovery in DCF were consolidated into the Office of
Public Benefits Integrity (OPBI). This office reported directly to the Secretary to ensure these functions were well integrated into the agency’s overall efforts.
In FY 2011-2012, OPBI increased savings through prevention efforts by eleven percent despite having fewer staff than the previous year. Existing technology was optimized to better detect fraud risk factors, such as identity theft. In one example, the identities of individuals currently incarcerated were being used to receive public assistance benefits. As of September
2012, the dollar value of fraud prevented had increased by ten percent since the beginning of 2011, while recoveries had increased by sixteen percent, to over $19 million.
Due to budgetary reasons, in September 2012, the OPBI contracted with Electronic Training
Solutions and The Stephen Group (ets/TSG) to conduct a review of OPBI’s Benefit Recovery unit.
The review sought to analyze Benefit Recovery’s organization, activities, policies, and procedures to determine opportunities for enhanced efficiency, process improvements, best business practices and opportunities for increased recoveries. OPBI has successfully implemented changes to support some of the findings and recommendations made by ets/
TSG. These changes included upgrades to the Benefit
Recovery database (Integrated Benefit Recovery
System) and reorganization of existing staff to enable more equitable statewide workload distribution and standardized processes. DCF also contracted with ets/TSG to complete a targeted processing of
Benefit Recovery’s referral backlog and develop a tool for workflow prioritization, expected to increase collections by more than ten percent. Phase I of the backlog reduction project resulted in establishment of 1,011 overpayment claims with a total value of
$840,036. If only fifty percent of those claims are collected, the return on investment for this phase of the project would be 138 percent. In 2013, OPBI collected $19 million in benefit overpayments.
Strike Force Recommendation: Additional eligibility determination and investigative staff are needed for DCF and DPAF.
Benefit Recovery also re-procured its outsourced collections contract for the first time in more than ten years with a redesign of practices and a prioritization model based upon the likelihood of collections on a claim. Key objectives included expanding the toolkit available for benefit recovery collections and creating an incentive based mechanism to maximize the state retained share of recoveries. Collections are expected to increase twelve percent (12%) annually. The new contract began December 31, 2013.
Strike Force Final Report 17

Manually Implemented Prevention Strategies.
OPBI has been involved in multiple initiatives involving manually executed strategies to detect and prevent fraud in the Supplemental Nutrition Assistance
Program (SNAP) program. Some of these are described here.
• Online Monitoring of Social Media.
Beginning in 2012, OPBI started monitoring social media sites, such as Craigslist, to identify individuals attempting to sell their Electronic Benefit
Transfer (EBT) Card. When such instances were identified, OPBI staff would contact the person who posted the information and inform them of the seriousness of their actions and the penalties associated with trafficking public assistance benefits. A form letter has been created to email social media individuals to explain the consequences of trafficking in benefits.
• Excessive EBT Card Replacement Monitoring.
Repeated requests for EBT card replacements can be a sign of fraud. Beginning in August
2012, DCF adopted a policy to track replacement requests, in conjunction with
Personal Identification Number utilization, and inform customers who replace their cards multiple times in a specified period that they have been placed on a “watch” list. These recipients were then subsequently monitored and reviewed at scheduled intervals.
• Action on Returned Mail.
DCF deployed an initiative to address the multitude of pieces of returned mail, due to insufficient addresses.
Returned mail can inform DCF of a recipient’s change of address or move. Between February and September 2013, DCF calculated $88 million in benefit savings by appropriately acting on returned mail.
• Address Analytics.
OPBI staff developed some basic address analytics, using already available data, which uncovered almost $10 million in benefit savings and won a Davis Productivity award.
Strike Force Recommendation. Better and faster employer data concerning employee identity and wages is needed at the time of public assistance benefit eligibility determination or renewal.
In addition, OPBI has been striving to secure better income information for eligibility determination and renewal. OPBI has been using the Work Number
[a service provided by Equifax] and other tools to access real time employment/income data which is much more current than the quarterly wage and hour data available from the Department of Economic
Opportunity. Although the Work Number is not currently available for statewide use for application eligibility processing, the new Medicaid Eligibility
System (MES) and connections to the federal hub will result in an increased connection to employment/ income information for Medicaid applicants. DCF will continue to review the scope of the information available and seek opportunities to improve program eligibility determination.
New Technologies.
On March 4, 2013, Florida became the first state in the nation to implement automated
Customer Authentication into their online public assistance application process. The new Customer
Authentication tool uses protocols similar to what is used in the banking industry to guard against identity theft. DCF obtained a special waiver from the United States Department of Agriculture (USDA),
Food and Nutrition Services (FNS) to conduct a pilot project in Florida. DCF worked with the United States
Department of Agriculture (USDA), developers, and vendors for over a year to build and incorporate this solution into the Automated Community Connection to Economic Self Sufficiency (ACCESS) application technology. During the 105-day pilot in the Central
Region, $237,600 in cost avoidance was identified as possible identity theft in SNAP alone. Customer
Authentication was fully implemented statewide on
August 1, 2013. The savings/cost avoidance through
December 2013 exceeded $14.7 million and cost less than $1 million to implement. Governor Rick Scott recognized DCF for the Customer Authentication initiative with the prestigious Governor Savings
Award. Total OPBI program integrity efforts in FY
2013-2014 to date have totaled over $47 million in savings.
In June 2013, DCF implemented the Florida
Department of Corrections (DOC) auto closure project. DCF matches its recipient base to DOC’s inmate population, weekly, and automatically closes any SNAP or Temporary Assistance for Needy
Families (TANF) case with a single person household identified as incarcerated. The match also prevents applications from being approved for any individual who is verified as someone incarcerated within the
Florida DOC system. From June through December
2013, DCF documented closing 3,238 cases resulting in $1.49 million in savings.
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A new Asset Verification System was launched in 2013 for use with Supplemental Security Income Medicaid applications. The Asset Verification System taps into financial institutions nationwide and identifies undisclosed assets to ensure that the applicant does not exceed the asset limit for Medicaid. Through
August 2013, $34.5 million in savings has been calculated from incorporating the use of this tool.
Strike Force Recommendation: As the state moves to statewide managed care, ensure the state is paying capitated insurance payments only on behalf of qualified beneficiaries and properly enroll Medicaid applicants and quickly disenroll recipients who are no longer eligible, due to other third party insurance, a move out-of-state, a lengthy incarceration, an increase in income, or death to prevent unauthorized payments to managed care entities.
In 2013, DCF implemented an automated notification system for recipients identified quarterly through the Public Assistance Reporting Information System
(PARIS) as receiving benefits in another state while also receiving benefits in Florida. To ensure proper action is taken on these cases and avoid duplicate participation, the system automatically sends out a notice requiring contact from the recipient before case closure. Since this project launched, approximately $170,901 has been saved due to more timely termination of benefits, and over $3.86 million in additional Tri-Care cost avoidance due to third party recoveries at the Agency for Health Care
Administration (AHCA).
Strike Force Recommendation: Examine the entire spectrum of public assistance delivery systems, not just at eligibility determination but also during receipt of benefits (e.g., EBT card trafficking, retailer fraud, provider billing fraud, overpayments, etc.).
Florida implemented a new MES with changes necessary to implement the Affordable Care Act effective January 1, 2014. The changes include new rules using Modified Adjusted Gross Income
(MAGI) to determine eligibility; a new web portal and application; and interfaces to the federal data hub, federal marketplace and the Children’s Health
Insurance Program. In October 2013, the system was already exchanging information with the federal data hub and marketplace to support the
Strike Force Final Report 19 required elements of open enrollment in the new marketplace. In November 2014, DCF is scheduled to implement technology that will capture the additional technological identification information from all applications submitted through the MES portal.
These advancements, along with the Public Benefits
Integrity Data Analytics and Information Sharing
Initiative at AHCA will help to ensure that only qualified providers, network providers and eligible beneficiaries are participants in Medicaid and other public assistance programs in Florida.
Procurement of New EBT Vendor.
In an effort to reduce fraud, waste and abuse in TANF; Women,
Infants and Children (WIC); and SNAP programs,
DCF initiated the process of securing a new vendor for the EBT system in May 2012 by issuing an
Invitation to Negotiate (ITN). The ITN solicited the latest technology available to combat fraud in these programs. Included in the EBT procurement were several fraud prevention/detection capabilities including predictive analytics and enhanced monitoring reports. The incorporation of real-time alerts to assist the Division of Public Assistance
Fraud (DPAF) in investigating retailers suspected of trafficking SNAP benefits was also explored with vendors.
On September 13, 2013, DCF transitioned to the new vendor, FIS, to administer the EBT payment system for the TANF, SNAP and WIC programs. FIS will provide Florida cutting edge anti-fraud analytics and a dedicated team of analysts for use by DCF and DPAF to combat trafficking and retailer fraud as well as other fraud in SNAP. New EBT anti-fraud tools have been incorporated into the practices of the new EBT vendor, including:
• New retailer tools to identify bad stores and recipients;
• A new fraud dashboard;
• A three-person team provided by FIS whose sole function is data analytics; and
• Identity theft related analytics involving the distribution of the EBT card.
Once fully implemented, anticipated savings in the first year alone are estimated at $4 million.

Partnerships.
Enhancing partnerships with federal, state and local law enforcement has also been a focus for OPBI. OPBI worked very closely with USDA in securing the waiver to implement the customer authentication system. In the past year, OPBI staff met with USDA FNS leadership to encourage consideration of avenues that would help Florida do a better job (including addressing some federal laws).
One weakness in the SNAP program which facilitates
EBT retail trafficking is the ease with which one can get authorized as an EBT vendor and the subsequent proliferation of vendors around the state.
USDA should consider the need for additional EBT retailers prior to authorizing new providers. This was suggested to the USDA FNS Undersecretary in a
2013 letter from the DCF Secretary and presented in a meeting with the Undersecretary by DCF and DPAF staff. The Agricultural Act of 2014 (“Farm Bill”) has addressed retailer/vendor issues and OPBI is currently awaiting policy information from USDA FNS. It appears that USDA FNS will require the stocking of certain staple food categories to meet SNAP retailer eligibility. (Note: At the time of this publication, states are awaiting implementation memoranda and policy making decisions on numerous Farm Bill provisions that impact eligibility and program integrity.)
Strike Force Recommendation: In follow up to the SNAP Fraud Rate study, identify federal and state legislative changes needed to strengthen the program (i.e., agency oversight, stronger penalties for fraud, etc.).
Because identity theft is a continuing major problem, especially in Florida, public assistance programs need to be able to make sure that those receiving benefits are clearly the eligible beneficiary, so that others in need do not go without. The Center for Medicare and
Medicaid Services (CMS) will soon require identity authentication as a part of the new application process for Medicaid. DCF continues to work with FNS in hopes that they, too, will require the authentication process within SNAP. FNS prohibits Florida’s authentication process to be required, allowing only for voluntary participation by applicants. This results in less than optimal results. During a recent meeting with USDA FNS Undersecretary, DCF provided data regarding the greater incidence of identity theft among ‘opt outs,’ which allow bad actors to skip the authentication process and burden eligibility staff with manually verifying a person’s identity.
20 Strike Force Final Report
OPBI also meets quarterly with DPAF to create a more streamlined and targeted referral process that allows DPAF to focus on the best cases for fraud investigations.
Public Awareness Campaigns.
Beginning May 2013,
OPBI launched aggressive media and public relations campaigns to engage and educate the public about fraud in public assistance programs. The multifaceted communications strategy includes a new fraud webpage, monthly press releases on anti-fraud initiatives, push notifications, YouTube videos, etc.
The campaign was deployed with the theme that if you receive public assistance benefits illegally, “It’s not IF we will catch you, but WHEN!
”
In 2014, OPBI published the joint public awareness videos produced by the Strike Force online. Three videos have been published on the OPBI internet home page aimed at educating the general public, recipients, and vendors on EBT cards and SNAP usage/ fraud. The video directs fraud complaints to the web page, www.myflfamilies.com/ReportFraud.
The new EBT vendor card scheduled for distribution in fall 2014 will also feature this fraud reporting web page on the reverse of the card.
Legislation.
OPBI’s efforts also received help through legislation. The 2013 Legislature passed a law that will prevent the use of EBT cards at certain establishments, thereby curtailing such fraudulent use of the cards. In April 2014, DCF added an online web form to the OPBI homepage that allows vendors with
ATM machines to self-report their locations to help populate the restricted list.
In 2014, House Bill (HB) 515 was sent to Governor
Scott for signature. This bill contains four provisions:
1. Increased criminal penalties for public assistance fraud – Establishes 3rd, 2nd, and 1st degree penalties with fraud barriers that align with Grand Theft provisions.
2. Reward Program – Requires DCF to pay rewards to individuals providing information to DCF, the Florida Department of Law Enforcement
(FDLE), or the Department of Financial Services
(DFS) DPAF relating to public assistance fraud resulting in a fine, penalty, or forfeiture.
3. Eliminates out-of-state TANF usage after 30 days – Individuals receiving cash assistance will have benefits terminated once they have used

their EBT card for 30 consecutive days outside of Florida. It is anticipated that this may prevent as much as $1.8 million in cash payments and assist anti-fraud initiatives.
4. Protective Payee – Allows for a protective payee to be established in cases where eligible children are living in a home with a parent or guardian that has been disqualified for fraudulent usage.
This will ensure that the children can still get their benefits through a designated surrogate protective payee.
AGENCY FOR HEALTH CARE ADMINISTRATION
Enhanced Case Management System.
In March 2010, a biennial review by the Office of Program Policy
Analysis and Government Accountability (OPPAGA) recommended that AHCA expand its detection tools to include neural networking and other advanced techniques for detecting emerging fraud and abuse patterns. AHCA had data analytic tools in use, but none were fully automated and none used external
(non-Medicaid) data from data aggregators. In 2011, the Florida Legislature authorized $800,000 for AHCA to replace its aging Office of Medicaid Program
Integrity (MPI) case management and tracking system incorporating or interfacing with advanced detection systems.
On April 17, 2014, a contract with Imager Software was executed after a competitive procurement and joint application development sessions are ongoing to develop and improve the quality of specifications for the new case management system.
Telephonic Home Health Services Delivery
Monitoring and Verification Program.
After one full year of piloting this strategy (described earlier in this report), AHCA reported a decrease of fifty percent from the prior year in claims paid for home health visits in FY 2010-2011. This program also resulted in a reduction in home health care visits by 51 percent during the same time period.
Because providers have twelve months from the date of service to submit claims for payments, final numbers are not readily available; however, the second year of the Delivery Monitoring and
Verification (DMV) program was expected to have generated substantial additional savings for Medicaid expenditures in Miami-Dade County. Preliminary statistics reported in September 2012 indicated that the dollar amount of claims paid in year two of the program was fifteen percent lower than in year one, an estimated additional savings of $3.5 million.
The second year’s savings are in addition to the $19 million cost reduction (a reduction of 46 percent) achieved in the program’s first year. During the 2012 legislative session, the Legislature directed AHCA to expand the DMV Project statewide, as well as the
Comprehensive On‐Site Care Management Project
(see page 7).
Legislation.
AHCA’s tools to fight against Medicaid fraud were enhanced with legislation adopted during the tenure of the Strike Force. During the 2011
Legislative session, the House and Senate passed HB
7107 and HB 7109 to reform the Florida Medicaid program requiring implementation of a statewide
Long Term Managed Care program and a statewide
Managed Medical Assistance program. Since Medicaid fraud and abuse had been recognized as primarily a fee for service system problem, the move to managed care was expected to reduce fraud and abuse in the system. Managed care was also recognized as a tool for using resources more effectively while improving outcomes. Identified benefits of managed care included:
• Increased accountability;
• Improved access to health care services;
• Greater flexibility since plans can offer services the state cannot;
• Improved predictability of cost; and
• Reduction in growth rate of expenditures.
House Bill 7107 established eleven regions in the state and AHCA was required to separately procure for Long Term Managed Care and Managed Medical
Assistance plans in each of the regions. The bill required timely implementation of the Long Term
Managed Care and Managed Medical Assistance programs with submission of a federal waiver request by August 1, 2011, and statewide implementation of the programs by October 1, 2014. The law prescribed the minimum and maximum numbers of plans in each region and specified the number of Provider Service
Networks that could participate. The prescribed number of plans allowed between thirty and 53 plans each for Long Term and Medical Assistance managed care.
Pursuant to Sections 409.91212, Fla. Stat., and
409.913, Fla. Stat., managed care plans are required to maintain anti-fraud plans. MPI will continue to monitor, review, audit and inspect these plans to
Strike Force Final Report 21

ensure that the plans provide Florida’s most vulnerable citizens with medically necessary and high quality healthcare.
AHCA is not the only agency that has responsibility for reviewing anti-fraud plans for Medicaid managed care organizations. State statutes prescribe DFS
Division of Insurance Fraud (DIF) oversight and approval of insurance companies’ required antifraud plans in accordance with Section 626.9891,
Fla. Stat. Statutes also prescribe AHCA oversight and approval of anti-fraud plans required by Medicaid
Managed Care Organizations (MCOs) in accordance with Section 409.91212, Fla. Stat. Recognizing this opportunity for better collaboration and coordination,
AHCA drafted an interagency agreement for consideration by DIF to facilitate the coordinated review of anti-fraud plans for Medicaid managed care organizations. This Agreement is under review and sets forth the parties’ roles and responsibilities to accept, review, correct as appropriate, and approve anti-fraud plans submitted by Medicaid MCOs licensed to transact insurance business in Florida.
Strike Force Recommendation: Require AHCA to enter into an interagency agreement with DFS’
Division of Insurance Fraud (DIF) regarding antifraud plans by MCOs.
The 2013 Legislature provided additional support for AHCA’s efforts to combat fraud and abuse in the
Medicaid program, through HB 939. The bill was signed into law by the Governor on June 7, 2013.
In this bill, Section 409.913(16)(j), Fla. Stat., was amended to enhance Medicaid provider controls and increase Medicaid provider accountability. This legislation requires that AHCA impose the sanction of “termination for cause” when a provider voluntarily relinquishes its Medicaid provider number after receiving written notice that AHCA is conducting or has conducted an audit, survey, inspection, or investigation and that a sanction of suspension or termination will or would be imposed for noncompliance.
Strike Force Recommendation: As the state moves to statewide managed care, ensure that new, antifraud prevention tools are put in place and that
MPI and MFCU are prepared for the transition to Managed Care and the new challenges it will create for the agencies.
The legislation also amended Section 409.920(8),
Fla. Stat., to provide immunity from civil liability for libel, slander, or any other relevant tort for sharing information about fraud or suspected fraud between
AHCA and MCOs. This protection should encourage the exchange of information between MCOs relative to discoveries of fraudulent behavior and suspected fraudulent acts and facilitate the reduction of fraudulent costs to the Medicaid program.
Strike Force Recommendation: Enhance protections from tort liability for persons who share information about suspected fraud by a provider.
Other provisions of HB 939 that will assist AHCA included:
• Thirty day notification of change of ownership required of providers.
Strike Force Recommendation: Require that a change in principal owner must be reported to AHCA within thirty days.
• An administrative remedy for “authorized” services that are unnecessary or harmful (prior restrictions only addressed services “ordered” or “prescribed” but some Medicaid service providers technically only “authorize” services).
Strike Force Recommendation: Hold providers accountable for care or services they authorized, even if they did not provide them.
• Requiring provider records presented in the defense of an overpayment case be prepared contemporaneously with the service provided.
Strike Force Recommendation: Limit the amount of time given to providers to submit additional documentation following issuance of an audit report.
• Establishing Leon County and the First District
Court of Appeal (DCA) as venues for sanctions and appeals in Medicaid cases.
Strike Force Recommendation: Establish
Leon County as the venue for sanctions.
22 Strike Force Final Report

Assisted Living Facility (ALF) Regulatory Concerns.
AHCA licenses assisted living facilities (ALFs) in
Florida. Potential violations of licensing standards, including concerns with ALF resident care should be reported to AHCA for regulatory review. Because
ALF residents are often involved with state service programs (such as Medicaid, elder care services through the Department of Elder Affairs, or elder abuse or substance abuse/mental health services through DCF) it is important to raise awareness of the need to report regulatory concerns in ALFs to AHCA.
To assist with this education and awareness, AHCA conducted several stakeholder sessions to emphasize reporting concerns and compiled a document listing specific instances in which they should be contacted to properly review the conditions observed at an
ALF. The list and reporting instructions can be found at: http://ahca.myflorida.com/MCHQ/Health_
Facility_Regulation/Assisted_living/docs/alf/ALF_
Observations_List.pdf. Similar tools were developed and outreach was conducted to address unlicensed
ALFs and how to identify and report concerns.
Assisted Living Facility (ALF) Enforcement Unit.
In 2011, AHCA established a unit of ten ALF surveyors to function as a team responsible for statewide oversight of ALF inspection enforcement and to serve as liaisons with local law enforcement and other partners such as the Long-Term Care
Ombudsman, Department of Health and DCF. The
ALF Enforcement team’s primary functions include:
• Investigating high priority complaints;
• Collaborating with other agencies and law enforcement;
• Participating in unlicensed activity investigations;
• Performing off hours or weekend inspections; and
• Conducting quality assurance reviews.
In 2012, AHCA enhanced the surveyor (inspector) training and focused on core areas of compliance such as resident rights, nutrition and food service, medication management, staff training and physical environment, in addition to proper licensure with the
State. Every surveyor must take the enhanced training course, ALF Surveyor Core Training, prior to being able to survey ALFs independently.
The goal is to ensure that all ALF residents receive appropriate healthcare. Facilities that provide substandard care as well as facilities providing care that exceeds the scope of the staff or the facility’s licensure increase the cost of healthcare for Medicaid recipients.
Non-Enrolled Prescription Provider Suspensions.
Beginning in October 2011, AHCA started to review all health care practitioners that were prescribing pain medication purchased by the Medicaid program in order to preclude Medicaid from paying for unnecessary or abusive prescriptions. Providers identified with high prescription rates and who were not actively enrolled in the Medicaid program were recommended for suspension from the Pharmacy
Benefits Management Program pursuant to Section
409.913(8), Fla. Stat., meaning that Medicaid would not pay for prescriptions written by the prescriber. As of September 30, 2012, 395 non-Medicaid-enrolled pain pill prescribers had been suspended from prescribing drugs to Medicaid recipients. The Agency continues to terminate prescribing rights of providers as deemed appropriate and necessary.
Data Connectivity Plan Update.
During 2012, AHCA revised the Strategic Plan for Data Connectivity:
Health Care Fraud Databases , first published in 2010, to document new databases that were identified that could assist in the fight against health care fraud and abuse, and to identify new opportunities to connect databases storing health care fraud related information.
AHCA issued the revised Strategic Plan on March
7, 2012. Continuously refining this Strategic Plan provides AHCA with a roadmap to ensure that all relevant information is available to assist them in its fight against health care fraud and abuse. The plan includes replacing AHCA’s current case tracking system employed by MPI with a replacement system that incorporates advanced detection methodologies.
Background Screening.
Electronic fingerprinting for Medicaid criminal background screening was established based on 2010 Florida legislative changes.
FDLE established a retained fingerprint system in
2010 allowing agencies to notify FDLE to retain fingerprints of their applicants and FDLE will in turn notify the agency if an arrest occurs for that individual. By statute, fingerprints are retained for schools, racinos, the Florida Department of Juvenile
Justice (DJJ), all criminal justice agencies, private schools, guardians, and those applicants who are
Strike Force Final Report 23

enrolled in the Care Provider Clearinghouse. The hit notifications are currently only for Florida arrests; however, the FBI is planning to allow for the same service nationally in the last quarter of 2014.
Background screening requirements apply to MCO network providers, including non-enrolled network providers of Medicaid MCOs and Provider Service
Networks.
Strike Force Recommendation: Require that non-enrolled providers be subjected to Level II background screening.
In 2012, the passage of HB 943 established requirements for submission of retained prints to a central Care Provider Background Screening
Clearinghouse. Retained prints enhance anti-fraud efforts by providing notification to AHCA upon the arrest of an individual who has been previously screened for Medicaid or employment. In addition, this legislation authorized the creation of a secure, web-based Care Provider Background Screening
Clearinghouse (Clearinghouse) to be housed at AHCA to manage screening results of health and human service agencies including Agency for Persons with
Disabilities (APD), Department of Elder Affairs, DCF, the Department of Health (DOH), the Department of Juvenile Justice (DJJ) and the Department of
Education’s Division of Vocational Rehabilitation
(DVR). The Clearinghouse created the infrastructure for sharing screening results across these agencies.
Retained prints will be implemented for these agencies as they are added to the Clearinghouse. AHCA also requested an extension of a federal background screening grant to complete the Clearinghouse. DOH screenings were added to the clearinghouse in 2013 and all other named agencies are expected to join the
Clearinghouse by December 2014.
Strike Force Recommendation: A retained print program that would provide immediate notification to AHCA of arrests for health care fraud is needed and federal checks and verification with DOH on licensing needs to be automated so that AHCA is notified as soon as a conviction occurs.
License Verification of Medicaid Providers.
In 2012,
Health Quality Assurance (HQA), the Agency’s licensing division, and the Division of Medicaid explored new data mining strategies, including using crosswalks between Medicaid provider types and HQA licensure requirements to identify Medicaid providers who should be further reviewed for potential licensure action and/or evaluation of continued Medicaid participation. This includes providers who have lost eligibility to participate by virtue of the loss of a license and providers who have had adverse licensure actions related to non-required licenses. In addition,
AHCA reports that a current license match occurs daily between licensed providers in Florida Medicaid
Management Information System (FMMIS), HQA license information and DOH license information thus sending an alert to FMMIS when a Medicaid provider may no longer be eligible to participate as a result of loss of a license.
Pain Pill Doctor Suspensions.
In February 2012,
AHCA began to routinely identify outliers in pain medication prescribing and reviewed the top
Medicaid pain medication prescribers for potential suspension from the Medicaid program or referral to the Medicaid Fraud Control Unit (MFCU). This initiative was launched to enhance the identification of provider over-utilization, increase recoveries of Medicaid funds for prescribing without proper documentation in medical records, and refer suspected pill-mill prescribers to other appropriate regulatory agencies and law enforcement. This review led to the immediate termination of prescribers who were responsible for dispensing pill mill type drugs.
Public Benefits Integrity Data Analytics and
Information Sharing Initiative.
The goal of this initiative is to better detect and deter fraud, waste and abuse in Medicaid and other public benefit programs within the state. In 2013, the Florida Legislature appropriated an initial sum of $3 million from the
Medical Care Trust Fund for the Public Benefits
Integrity Data Analytics and Information Sharing
Initiative followed by an appropriation of $5 million in 2014 for the continuation of the initiative to enhance and accelerate the identification of improper billing trends in the Medicaid program and provide early detection of anomalies. The scope of this project will include risk scoring, a cross-matching or link analysis of certain enrollment and licensure data with other demographic data and pattern analysis. This enhanced capability will allow AHCA to track multiple parties affiliated with pain clinics, pharmacies and other sources of medical supplies
24 Strike Force Final Report

and provide link analyses to identify associations with fraudulent providers. The Agency has selected the data analytics vendor, SAS Institute, to assist in implementation of the project.
Strike Force Recommendation: Track affiliated owner and business managers, (and others) of pain clinics, pharmacies and other sources of medical supplies/drugs to enable link analyses that could identify potential fraud.
DEPARTMENT OF HEALTH
Division of Administration.
The Contract
Administrative Monitoring unit has been active in monitoring sub-recipient contracts and obtaining payback of unexpended funds. If fraud is detected, the contract is forwarded to the Inspector General’s office. The bulk of what Administration does in this area is ensuring the program offices adhere to policy regarding dual signatures on invoices.
The Florida Women, Infants, and Children Program.
The Florida Women, Infants and Children (WIC)
Program uses the program abuse prevention techniques of COMPUSTAT. This process uses data system technology and data sharing to identify areas of program abuse and focus the application of appropriate resources to counter the indicators of abuse and curb or prevent abuse through consistent vigilance and attention. This process also highlights personal visits to WIC grocers (vendors) throughout
Florida at least annually. For example, DOH evaluates
EBT activity daily for indicators of program abuse.
This process holds all vendor redemptions to certain prescribed monetary limits. Redemptions beyond those limits are automatically recouped. WIC requires vendors periodically to provide, on a no-notice basis, invoice records to substantiate selected EBT transactions and redemptions. Any redemption not supported is recouped. The redemption issues are communicated to the vendors for corrective action and department follow-up.
WIC performs daily analysis of social media sites for indications of program abuse. Social media activity is evaluated against known WIC prescriptive patterns to identify potential program abuse. When indicators are found, WIC notifies those who may be involved to curb or prevent abuse through positive, proactive counseling and further program assistance or training where required. These are examples of approaches that create an environment in which program abuse is more obvious and compliance is far simpler. Each technique directly addresses and discourages a variety of tactics intended to subvert the intention of the WIC
Program.
Data/Risk Management Team.
The Data/Risk
Management statewide team has made several recommendations to executive leadership related to personal identifying information and how DOH can better manage the risks associated with capturing this type of information. Some recommendations are for policy change and some are technological solutions.
New Business System Development.
New systems developed (such as the Year End Forms Project) are implementing history tables to aid in audit tracking.
Health Management System Identity Theft Risk
Mitigation.
The Health Management System (HMS) is the Florida DOH practice management system and certified Electronic Health Record in use in the
67 county health departments (CHDs). The HMS contains extensive clinical and billing data related to the services provided for DOH clients. In order to further safeguard the identity of clients, DOH implemented several measures to restrict and control the availability of social security numbers (SSNs) within the HMS. Following extensive analysis to determine the most appropriate utilization of this vital identifier within the CHD business processes, additional security measures were implemented.
The security measures included the application of
‘masking’ characters that replace the first 5 digits of a client’s SSN with non-numeric special characters.
This mask was integrated into all client search pages, reports and application client detail screens displaying
SSN as a unique identifier. Where appropriate, DOH replaced the use of a SSN with other client identifiers throughout the application. In order to not impede the business processes, the application needed to continue to allow searching for clients using the SSN.
Therefore, restrictions were implemented requiring the entry of a complete SSN to perform a search, thereby preventing searching on partial SSNs that would return lists of results. Analysis of the business processes identified situations where utilization of a SSN as a unique identifier by a subset of staff is absolutely required. In order to accommodate this exception, new security options within the HMS
Security Profile permit the granting of user access to view SSNs within the application. This elevated privilege must correspond with the job duties and responsibilities of CHD employees and is limited
Strike Force Final Report 25

to only individual client records and not reports that include lists of clients. Client searches were identified as the most significant area of vulnerability and therefore the SSN was completely removed regardless of the users’ assigned security privileges.
Modifications to this security profile feature are appropriately logged within the application. The DOH also issued guidelines to CHD security administrators regarding the most appropriate application of this elevated access.
Emergency Suspension Orders.
In 2009, Senate
Bill (SB) 1986 was passed to go into effect July 1,
2009. This law required that DOH deny licensure or renewal for practitioners with felony convictions and/or Medicare/Medicaid terminations for cause and gave DOH the authority to take action against providers for failure to remit overpayments to AHCA.
The 2012 Florida Legislature followed that with the passage of HB 653, effective July 1, 2012, which further prohibited licensing or renewing the license of individuals with certain felony convictions related to health care fraud. This was intended to increase the number of licensees subject to license denial/nonrenewal.
One challenge that DOH faced in implementing this new provision related to felony convictions was getting timely information on convictions from the Clerks of Court in Florida. As of September,
2012, DOH was obtaining a monthly file from the
Clerks’ Comprehensive Case Information System that includes new arrests and convictions. This information is used to compare against licensed practitioners and determine if any further action is necessary. Automating this information sharing would definitely be more efficient, however, that has not been possible.
Strike Force Recommendation: Conviction information from the Clerks of Court needs to be conveyed to DOH in a more efficient manner.
SB 1986 also authorized DOH to issue an emergency order suspending the licenses of providers who had pled to, been found guilty of, or pled nolo contendere to certain felonies and misdemeanors related to the
Medicaid program. This led DOH to change their priority categories for issuing Emergency Suspension
Orders. In FY 2010-2011, emergency actions were issued in an average of 106 days. As a result of process improvements identified through mapping, an aggressive target was set to issue emergency actions in less than thirty days from receipt of a priority complaint beginning July 1, 2011, and removing or restricting licensed individuals who are not safe to practice. For FY 2011-2012, a total of 376 emergency actions were issued in an average of 74 days with 41 percent issued within thirty days. The number of emergency actions issued increased sixteen percent from FY 2010-2011.
Prescription Drug Monitoring Program. The
Electronic-Florida Online Reporting of Controlled
Substances Evaluation program (E-FORCSE®) is the name of Florida’s Prescription Drug Monitoring
Program (PDMP). E-FORCSE® was created by the
2009 Florida Legislature in an initiative to encourage safer prescribing of controlled substances and reduce drug abuse and diversion within the state. The purpose of E-FORCSE®, which became active September 1,
2011, was to provide information to guide health care practitioners’ prescribing and dispensing decisions regarding highly abused prescription drugs.
Through this initiative, DOH was working to:
• Reduce the rate of inappropriate use of prescription drugs through department education and safety efforts;
• Reduce the quantity of controlled pharmaceutical substances obtained by individuals attempting to engage in fraud and deceit;
• Increase coordination among partners participating in the prescription drug monitoring program; and
• Involve stakeholders in achieving improved patient health care and safety and reduced prescription drug abuse and prescription drug diversion.
Since the E-FORCSE® became active, DOH has continued to track the activity within the system, as well as the impact. DOH reported that as of the end of
August 2013:
• 85 million prescription records had been uploaded by 7,005 dispensers;
• 60,058 Florida prescribers had issued one or more controlled substances during the prior year; and
• 11,118 prescribers and 11,497 pharmacists had registered and queried the database over 5.8 million times to view their patient’s controlled substance history.
26 Strike Force Final Report

In addition, there was an eighteen percent drop in oxycodone related deaths in 2011, as compared to
2010. Subsequently, there was a 29.1 percent drop in oxycodone related deaths during the first six months of 2012, as compared to 2011.
Overall, when comparing multiple provider episode rates (doctor shopping) by drug class between the first quarter of 2013 to the first quarter of 2014, there was a 22 percent decrease in opioids prescribed; 18 percent decrease in stimulants prescribed; and 27 percent decrease in benzodiazepines prescribed. DOH is continuing to see downward trends in individuals seeing multiple providers for opioids, stimulants, and benzodiazepines.
DOH works closely with DBPR, Drugs, Devices and
Cosmetics Program, Controlled Substance Registry program to monitor Zohydro sales data. Sales data is being compared to dispensing data from the PDMP to identify abuse, misuse and diversion. From January 1,
2014, through May 31, 2014, 325 individuals received
453 Zohydro prescriptions. A total of 25,067 capsules in various strengths have been dispensed throughout the state.
With the exception of a one-time appropriation of
$500,000 for FY 2013-2014, no state funds or funds received directly or indirectly from prescription drug manufacturers have been used to support the PDMP.
In June 2014, Attorney General Pam Bondi donated
$2 million to the PDMP Foundation for the ongoing operations of the PDMP. The fines were collected as a part of a settlement agreement with CVS Care Mark.
Licensure Actions.
SB 1986 (2009) enacted a number of disqualifications for licensure, certification or registration under Section 456.0635, Fla. Stat. This section mandates, among other things, that each board within DOH, or DOH, if there is no board, shall refuse to issue an initial license or to renew a license if an applicant has been convicted of a felony, including
Medicaid and other types of health care fraud.
Since the law went into effect, 167 applicants have withdrawn their application, had their application denied, had their license revoked or relinquished due to disciplinary action or were denied renewal of their license due to fraud convictions. Of these denials or actions, 44 were specifically related to Medicaid fraud.
Partnerships.
DOH continues its partnerships with
AHCA and MFCU, in the Office of Attorney General
(OAG), to strengthen interagency coordination and enhance processes and protocols in fraud investigation and prosecution. An interactive partnership is essential for effective, collaborative, investigative efforts aimed at protecting the people of Florida against healthcare fraud and substandard health care.
Directors and enforcement leadership from DOH meet regularly with AHCA and MFCU directors and senior managers to coordinate joint projects, investigations and enforcement strategies and to identify emerging issues or threats. During the past year, participation in these meetings grew to include several additional state agencies, including
DCF, the Strike Force, the Department of Economic
Opportunity (DEO), the DFS Division of Insurance
Fraud and APD. Expanding participation in the bimonthly meetings fosters a multiagency approach to fraud mitigation and identifies emerging areas of fraud and areas in which agency resources can be more effectively leveraged.
In an example of enhanced agency collaboration,
AHCA and DOH recently identified an opportunity to work more closely together to combat the growing problem of unlicensed ALFs. At the first of scheduled quarterly meetings, in August 2013, the two agencies reviewed processes, shared best practices and trained staff on statutory and administrative rule requirements. By leveraging field resources in the identification of unlicensed ALFs and streamlining reporting requirements, both agencies expect to see more regulatory and criminal prosecutions in the future.
Some examples of other joint operations involve investigations where subjects made fraudulent disability claims for an individual that was not disabled; subjects fraudulently billing multiple insurance carriers for various therapies, such as massage; as well as massage schools that issued fraudulent transcripts to individuals that had not completed required coursework. From July 1, 2009, through March 19, 2014, the DOH has denied licensure to 394 applicants and denied license renewal of 133 healthcare practitioners for health care related fraud. In addition, the DOH has taken 141 emergency actions and disciplined 224 healthcare practitioners for violations related to Medicaid.
AHCA and DOH also continue to enhance information sharing to ensure compliance with antifraud legislation. For example, DOH transfers data every 24 hours to AHCA to flag practitioners who do not have an active license but who may continue to be billing Medicaid.
Strike Force Final Report 27

OFFICE OF ATTORNEY GENERAL
Efforts of the OAG and the MFCU, in particular, have been focused on preparing for the changes in fraudulent schemes that will emerge with the implementation of statewide managed care in
Medicaid.
Strike Force Recommendation: As the state moves to statewide managed care, ensure that new, antifraud prevention tools are put in place and that
MPI and MFCU are prepared for the transition to Managed Care and the new challenges it will create for the agencies.
Partnerships.
The MFCU strives to coordinate its efforts with partner agencies at every governmental level, particularly through task force and strike force activities, as well as associations and professional organizations.
The United States Department of Health and Human
Services (HHS) also assigned a dedicated federal prosecutor to work on joint Medicare-Medicaid cases with the Florida MFCU. HHS also provided training for investigators and supervisors that will focus on managed care fraud and offered to sponsor Florida staff to attend any federal training on managed care.
The MFCU has assigned an investigator to assist with multiagency investigations and help determine if Medicaid fraud is also evident in Medicare fraud cases.
In addition, AHCA and MFCU staff meet regularly to discuss referrals and streamline the intake process.
That has been very successful in helping AHCA staff prepare referral packages that MFCU has preapproved for successful prosecution. MFCU provides feedback on initial referrals and AHCA refines them to prepare a final referral package to go to MFCU.
Staffing.
In FY 2011-2012, MFCU began increasing their analytical staff to prepare for the move to managed care.
With the move to statewide Medicaid managed care, it is necessary to hire qualified personnel who will be better prepared to work with the managed care cases and MFCU continues to prioritize the goal of maintaining appropriate staff levels throughout the state. MFCU has conducted an assessment of staffing and office locations to insure that they meet not just current needs but anticipated needs for enforcement.
28 Strike Force Final Report
MFCU also refined their process for handling complaints and making referrals to local offices.
MFCU Data Mining.
The MFCU data mining waiver project has continued and, in 2013, CMS extended the MFCU data mining waiver through December
31, 2014. The extension also provided that the three analysts could devote up to 75 percent of their time to the project starting October 1, 2013. MFCU is also seeking to expand its data mining activities through a cloud platform containing advanced data detection.
An ITN for procurement was issued in 2013 for this purpose.
As of March 31, 2014, the MFCU had submitted 74 data mining projects to AHCA for review and 61 were approved. MFCU also opened 31 cases from these projects and is currently developing other information. One arrest has been made as a result of the current data mining initiative.
Also in 2013, as a result of Florida’s successful waiver program, HHS adopted a policy to allow all state
MFCUs to engage in data mining.
DEPARTMENT OF FINANCIAL SERVICES
For DPAF, the underlying theme for their efforts in the past three years has been building partnerships.
DPAF has been meeting quarterly with OPBI to discuss ways to improve effectiveness and coordination between the agencies. DPAF also participated in meetings with OPBI and the new EBT vendor to help develop a better system to detect fraud.
State Law Enforcement Bureau Operation Expansion.
In an effort to expand law enforcement activities to address retail fraud (or trafficking) in the USDA
SNAP program, the DPAF has been orchestrating the formation of partnerships with local law enforcement agencies around the state for the past three years.
DPAF held conferences in September 2012 and July
2013 to increase awareness of what the State Law
Enforcement Bureau (SLEB) for EBT cards in Florida does and how they collaborate and coordinate with federal and local law enforcement agencies to combat trafficking in the SNAP program. The 2012 conference was attended by about 100 people from around the state and the country and over half of them were from local law enforcement agencies in Florida. A total of
29 in-state (including a number of Florida regulatory agencies) and thirteen out-of-state agencies were represented.

Conference sessions focused on encouraging participants to become SLEB partners by entering into an agreement to coordinate with the SLEB in conducting investigations and follow program requirements as designated by USDA. Sessions covered the procedures for getting clearance to conduct an operation at a particular retail establishment as well as the diverse other criminal activities that may be uncovered during a SLEB trafficking operation. This was a particular high point of the conference because it clarified how working as a
SLEB partner could actually work to the advantage of local law enforcement that may have suspicions about other activity at the retailer’s location.
Strike Force Recommendation: Offer enhanced anti-fraud training opportunities and workshops involving both law enforcement and regulatory personnel within Florida to build collaborative, multiagency efforts to suppress emerging fraud trends.
Following that conference, ten agencies signed on as partners. DPAF issued EBT undercover cards to these agencies. These cards have already been used in 42 retail fraud investigations.
The SLEB held a second conference in July 2013 in Clearwater, Florida. There were 130 people in attendance and 25 different local law enforcement agencies represented along with four different states and the District of Columbia. The speakers included
Florida Chief Financial Officer Jeff Atwater, USDA
Undersecretary Kevin Concannon, and Strike Force
Director Chuck Faircloth. Following this conference the number of SLEB partners increased from twelve to sixteen and there have been four more inquiries.
At the conference, the Florida SLEB received recognition from USDA FNS Undersecretary
Concannon for their efforts and USDA expressed interest in using the Florida SLEB as a model for the nation.
As of March 2014, the SLEB partnerships have increased to twenty-five state and local law enforcement agencies that target retailers suspected of abusing the SNAP benefit program in their area.
DPAF plans to shift its efforts from conducting statewide conferences to appearing at Florida Sheriff ’s
Association and Florida Chiefs of Police annual conventions. These conventions provide the SLEB
Strike Force Final Report 29
Coordinators the opportunity to interact directly with heads of law enforcement agencies to market the SLEB program and its benefits.
OPS Criminal Intelligence Technicians.
In anticipation of the additional workload that will be created with the growing partnerships through the
SLEB, DPAF requested and received funding from the 2013 Legislature for ten OPS positions that are being used to review activity records of disqualified stores and pursue investigations of recipients who participated in trafficking schemes. This unit was launched on July 22, 2013. Ten Criminal Intelligence
Technicians for the EBT Trafficking Unit under the
Office of Statewide Investigations and Programs were hired to mine data on recipients who had used their cards at a now-disqualified retailer and appeared to be engaged in a pattern of activity identified as trafficking. Between July 2013 and March 2014, the
EBT Trafficking Unit completed investigations on
1,223 individuals that led to disqualification from the
SNAP program. SNAP benefits totaling $857,000 were trafficked by the individuals and the disqualifications resulted in nearly $2 million in SNAP benefits from being issued.
Strike Force Recommendation: Additional eligibility determination and investigative staff are needed for DCF and DPAF.
The unit has also given DPAF the ability to advance its investigative strategy of focusing on the most egregious cases of fraud first, resulting in a 47 percent increase in the number of investigations referred to the State Attorney. These cases, which are often more complex and time-consuming, are the best use of
DPAF investigators’ skills and talents.
Cooperative Disability Investigations.
An initiative by the Social Security Administration (SSA) to develop regional investigative units known as
Cooperative Disability Investigation (CDI) units employ state investigative personnel to conduct disability fraud investigations. The CDI unit in
Florida is housed in Tampa and currently consists of two DPAF investigators under the operational supervision of an SSA special agent that heads the
CDI unit. These DPAF investigators, whose salary and benefit costs are fully reimbursed by SSA, conduct undercover investigations of individuals who receive or have applied for federal disability benefits and reason exists to believe the individuals have provided false information. When disability determinations

are made, individuals receive both SSA and non-
SSA benefits, including SNAP and Medicaid-related benefits. Through this investigative effort, the DPAF investigators closed 141 cases between July 2013 and
March 2014, resulting in $14,653,370 in SSA and non-
SSA benefits being withheld.
Benefit Matching Initiatives.
Based on the fraud percentage revealed by the independent Strike Force fraud rate study (see page 38), over $432 million in
SNAP benefits alone are being fraudulently received based on $5.77 billion in SNAP issued in FY 2012-
2013 in Florida. In counties with exceptionally large recipient populations, the number of suspected fraud cases referred to DPAF may not be representative of the recipient population. In these instances, a benefit match will be conducted that identifies those households that report no income yet income has been reported by an employer of a household member to the Florida Department of Revenue. These benefit matches are viewed as a means of bridging the divide between suspected fraud reports received from
DCF and the work needed by investigators covering densely-populated counties. These matches also provide a basis for selecting cases with a potential for higher-dollar recoveries than those received from
DCF without this additional information.
DEPARTMENT OF LAW ENFORCEMENT
The biggest contribution from the Florida Department of Law Enforcement to the war on Medicaid fraud came from their promotion of an initiative to fight the fraudulent prescription and distribution of powerful narcotics. In spring of 2011, FDLE provided
$828,059 in Justice Assistance Grant/Byrne Memorial
Law Enforcement Grant funds to establish seven
Regional Drug Enforcement Strike Forces (RDESF) to pursue investigation and prosecution of illegal prescription drug operations (pill mills). The RDESFs were organized in March 2011 and grant funds were awarded in April 2011.
The RDESF efforts included multi-disciplinary investigations of doctors and pain clinics that were criminally and/or administratively violating the letter and/or spirit of Florida’s Medicaid laws and regulations.
The goals of the RDESFs are to identify, investigate, and apprehend medical doctors and close clinics and pharmacies fraudulently prescribing and dispensing powerful narcotics. The grant funds were used for a variety of activities, including officer overtime, controlled buys, expert witness fees, training and purchase of investigative equipment, some of which was directly targeted at fraud in Florida’s Medicaid and public assistance programs.
As of December 2013, RDESF efforts statewide had resulted in the arrest of 4,326 individuals (including
78 doctors); the closure of 254 clinics; and the seizure of 876,227 pharmaceutical pills, 146 vehicles, 578 weapons and $11,261,313.
According to the 2012 Medical Examiners Report, the number of drug-related deaths decreased 8.8 percent
(805 less) from those reported in 2011.
When compared to the 2010 Medical Examiners
Report, deaths caused by oxycodone decreased by 52 percent (781 fewer deaths) and overall prescription drug-related deaths decreased by 23 percent (620 fewer deaths).
LOCAL LAW ENFORCEMENT
In addition to the partners being groomed through the SLEB, other local law enforcement agencies have grown to appreciate the value of getting involved in fighting public assistance fraud at the local level. They have recognized the value of leveraging resources with state and federal agencies to enhance detection, investigation and enforcement efforts.
Strike Force Recommendation: Increase leveraging of resources to minimize costs to the state. In particular, it was recommended that agencies partner with local and federal agencies to enhance detection, investigation and enforcement efforts.
Palm Beach County Sheriff ’s Office.
Historically,
Palm Beach County Sheriff ’s Office (PBSO) investigators concentrated on identifying housing fraud schemes in their pursuit of public assistance fraud investigations. These partnerships have continued and evolved in the last two years, detecting and pursuing more complex and sophisticated fraud schemes. A recent joint operation was disclosed in a press release issued on August 1, 2013. According to the press release:
According to the indictment, Valle-Clas obtained two social security numbers
(SSN), one which was originally associated with her birth name, “Nereida Valle,” and one of which was originally associated with
30 Strike Force Final Report

the name “Gloria Lopes Clas.” From at least December, 2003, to January, 2013, she used the SSN for “Nereida Valle” to obtain federal housing, social security, food, cash, and medical benefits from the United
States Department of Housing and Urban
Development (HUD), SSA, USDA and
HHS. At the same time, she used the SSN for “Gloria Lopes Clas” to buy real estate in both Broward and Palm Beach Counties, including over an acre of property in
Loxahatchee, Florida on which she built an approximately 2,700 square foot residence.
Her husband, Gonzalez, also bought real estate in Broward County. When applying for federal benefits, she failed to disclose her or her husband’s ownership of property, as well as other assets and income. In 2009, after obtaining over $330,000 in mortgages on the Loxahatchee Property, Valle-Clas failed to disclose her receipt of federal benefits in obtaining a $145,000 loan charge-off.
In FY 2012-2013, the PBSO quickly moved into the arena of SNAP fraud. From March 2012 to the present, PBSO and USDA Office of Inspector General
(OIG) agents have collaborated to conduct several monitored undercover “buys” at convenience stores within Palm Beach County. These types of operations identified over 200 SNAP benefit recipients who willfully committed the offense of public assistance fraud trafficking in food stamps, a violation of Section
414.39 (a)(b)(c), Fla. Stat.
Miami-Dade Police Department.
In July 2013, members of the Economic Crimes Bureau of the
Miami-Dade Police Department (MDPD) met with staff from the MFCU. They discussed ideas and explored efforts that could be taken to promote better collaboration between MDPD and MFCU.
They established a willingness to work together on
Medicaid cases that would be of mutual concern to both agencies.
This meeting proved to be fruitful, introducing an opportunity to begin a promising collaboration between the agencies. MFCU staff offered to serve as a resource for MDPD, and invited the Economic
Crimes Bureau staff to an MFCU Training Session at the HHS OIG Headquarters in Miami Lakes, Florida.
MDPD staff attended this training, and found it to be extremely informative.
MFCU staff also committed to inviting MDPD staff to future pertinent forums with other partnering agencies where MDPD staff could be active participants. This will assist MDPD in establishing guidelines and building important partnerships in furthering efforts to combat Medicaid fraud cases.
Miami-Dade County State Attorney’s Office.
The
Miami-Dade County State Attorney’s Office reported activity in addressing fraud also. In 2013, the office filed 37 cases of public assistance fraud. Since the beginning of 2012, the office has filed approximately eighty cases of unemployment compensation fraud, as well as approximately seventy cases of Worker’s
Compensation fraud. This is in addition to cases the office has filed which involved the theft of grant money.
MEDICAID AND PUBLIC ASSISTANCE
FRAUD STRIKE FORCE
In addition to gathering more information on existing anti-fraud resources and strategies, tracking changes to and progress made in the fraud fighting landscape and identifying where enhancements could be made, the Strike Force also established a structure of working committees that facilitated their work.
Grants Committee.
A Grants Committee was established in July 2011 with representation from each of the state agencies that holds a seat on the Strike
Force.
The purposes of this Committee were:
1. To research and identify appropriate grant programs for the Strike Force and/or its partners to pursue.
2. To assist with pursuing funding opportunities for the Strike Force and/or the partner agencies.
3. To provide guidance on the development of a grant initiative for the Strike Force in which the
Strike Force is the grantor.
4. To review applications and make recommendations to the Strike Force for grant awards under the Strike Force grant initiative.
In 2012, the Grants Committee facilitated the submission of two funding requests for about $3.89 million. One was pursued in hopes of fully funding the Data Connectivity plan for AHCA. Another was sought to provide startup support for Customer
Authentication for DCF.
Strike Force Final Report 31

In 2013, no relevant, interagency collaborative funding opportunities were announced. However,
Strike Force staff facilitated the submission of two funding requests for projects that could apply academic rigor to continued investigation into fraud.
One was a request for $500,000 submitted by the
Florida State University (FSU) School of Criminology to research and evaluate EBT retail fraud as white collar crime. Another was a small request for funds to provide support for a policy conference on insurance fraud to be held in Tallahassee, through a collaboration of different academic departments at
FSU being led by the Center for Insurance Research.
The Grants Committee also held discussions on the possibility of overseeing a granting initiative by the
Strike Force. They reviewed sample grant application forms and discussed evaluation criteria for proposals that may be submitted. Although a granting initiative by the Strike Force was discussed and initial planning occurred, this initiative was never funded.
Mapping Committee.
The Strike Force also established a Mapping Committee in July 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this
Committee were:
1. To advise the Strike Force in the development of a tool that could provide a succinct picture of the anti-fraud processes in the Medicaid and public assistance service systems.
2. To advise the Strike Force on priorities for mapping business processes on vulnerable points within the Medicaid and public assistance service systems.
With guidance from this committee, the Strike
Force undertook a project to develop a very high level representation of the prevention, detection, investigation and recoupment of funds processes across the agencies that are primarily responsible for combating fraud in the Medicaid and public assistance service systems. The Strike Force worked with AHCA to utilize their prevention, detection and recoupment process maps developed as a result of SB 1986 (2009).
Advanced Systems Design (ASD), an information technology and government consulting firm, was hired as a process mapping consultant for this project.
The mapping committee helped direct the work of
ASD to develop a high level visual representation of the prevention, detection, investigation and recoupment of funds processes across the agencies that are primarily responsible for combating fraud in the Medicaid and public assistance service systems.
32 Strike Force Final Report
AHCA’s process maps, while focused on Medicaid provider fraud, were replicated to include recipient and public assistance business practices. The resulting high level overview is shown on the next page and more detailed descriptions of each of the circles depicted are presented on the following two pages.
The picture on the next page reflects the general areas that were considered in order to create a high level overview of the antifraud processes across all of the agencies that are involved in the Medicaid and public assistance fraud service delivery systems. At the earliest point in the process (top circle), the efforts focus on prevention and include activities that would generally be categorized as Screening, Education,
Application & Payment Reviews and Oversight &
Controls processes. These are processes that take place before a payment is ever issued to a beneficiary or provider.
The processes in the next circle, to the right, target the detection of fraud after a payment has been made. These activities are generally categorized as
Monitoring & Regulation; Data Mining & Detection;
Site Visits, Surveys & Audits; and Case Management &
Investigations.
The last circle (bottom left) focuses on the processes to recover funds and other resources lost as a result of fraud and/or abuse. These general activity categories include Claim Adjustments, Sanctioning, Litigation &
Prosecution, and Collections.
The triangle at the bottom of the figure indicates that there are three populations that must be monitored by these activities: Recipients (or beneficiaries of services), Providers and Employees of the agencies that administer the programs.

Screening
Oversight &
Controls
Education
Application &
Payment Reviews
Claim
Adjustments
Collections Sanctioning
Litigation &
Prosecution
Monitoring &
Regulation
Case Mgmt. &
Investigations
Data Mining
& Detection
Site Visits,
Surveys & Audits
INTER-AGENCY ANTI-FRAUD AND ABUSE PROCESS FRAMEWORK
Strike Force Final Report 33

KEY AGENCY FRAUD & ABUSE
PREVENTION PROCESSES
9 - Integrity oversight, prevention controls, & self-assessments targeting providers. (AHCA IG)
1 - Healthcare professional licensure.
(DOH MQA)
2 - Background screening and ed. for providers dealing primarily with the disabled. (APD)
3 - Facility licensure and
PREVENTION site visits for federal certification as a Medicaid provider. (AHCA HQA)
7 - APD recipient eligibility determination screening. (APD)
1 - Healthcare professional licensure.
(DOH MQA)
PROCESSES TO AVOID
FRAUD AND/OR ABUSE
4 - Approval of 9 - Integrity oversight, prevention controls, & self-assessments targeting providers. (AHCA IG)
6 - Recipient eligibilty determination screening.
2 - Background screening and ed. for providers dealing primarily with the disabled. (APD)
(DCF ACCESS)
8 - Provider claim edits, pre-payment reviews, and other reviews.
(AHCA, MS, MCM, & MPI)
3 - Facility licensure and site visits for federal certification as a Medicaid provider. (AHCA HQA) and provider ed. (AHCA Dir.’s Office,
7 - APD recipient eligibility determination screening. (APD)
MCM & Area Offices)
Legend
AHCA
DCF
6 - Recipient eligibilty determination screening.
(DCF ACCESS)
4 - Approval of managed care provider health plans/contracts.
(AHCA HQA & HSD)
DOH
APD
OAG/MFCU
DFS/PAF
5 - Medicaid policy dev., enrollments, and provider ed. (AHCA Dir.’s Office,
MCM & Area Offices)
Legend
Processes to avoid fraud and/or abuse prior to payments
DCF
DOH
APD
OAG/MFCU
DFS/PAF
The circle above and the next two depict the various processes employed by the different stakeholder agencies
(color-coded to match the agency engaging in that process) in Prevention (above), Detection and Recoupment.
34 Strike Force Final Report

KEY AGENCY FRAUD & ABUSE
PREVENTION PROCESSES
9 - Integrity oversight, prevention controls, & self-assessments targeting providers. (AHCA IG)
1 - Healthcare professional licensure.
(DOH MQA)
2 - Background screening and ed. for providers dealing primarily with the disabled. (APD)
3 - Facility licensure and and other reviews. site visits for federal
(AHCA, MS, MCM, & MPI)
PREVENTION certification as a Medicaid provider. (AHCA HQA)
KEY AGENCY FRAUD & ABUSE
PREVENTION PROCESSES
1 - Healthcare professional licensure.
7 - APD recipient
(OAG/MFCU)
1 - Provider site visits and audits. (AHCA MHC, HSD,
HQA, MPA, MPI & MQM)
10 - Internal and external
6 - Recipient eligibilty
(DCF ACCESS)
2 - Monitoring, inspections and regulation of health care professionals. (DOH MQA)
PROCESSES TO MONITOR,
DETECT, OR INVESTIGATE
FRAUD AFTER AN INSTANCE
OF FRAUD AND/OF ABUSE managed care
3 - Monitoring and regulation of providers dealing with disabled. (APD)
HAS OCCURRED provider health
KEY AGENCY FRAUD
AND ABUSE DETECTION
PROCESSES
9 - Case management and
(DOH MQA) internal/external fraud investigations of providers.
DETECTION
(AHCA IG & MPI)
Legend
9 - Integrity oversight, prevention controls, & self-assessments targeting providers. (AHCA IG)
2 - Background screening and ed. for providers investigations. dealing primarily with the disabled. (APD)
MCM & Area Offices)
(APD)
AHCA
DCF
DOH
7 - Recipient eligibility verification investigations.
(DCF ACCESS Integrity)
5 - Home visits and audits of providers and facilitators. (AHCA)
APD
OAG/MFCU
8 - Provider claim edits, pre-payment reviews, and other reviews.
(AHCA, MS, MCM, & MPI)
7 - APD recipient eligibility determination screening. (APD)
6 - Recipient eligibilty determination screening.
(DCF ACCESS)
PREVENTION
Processes to avoid fraud and/or abuse prior to payments site visits for federal
6 - Home visits and audits of providers. (APD)
Legend
AHCA
certification as a Medicaid
DFS/PAF
APD provider. (AHCA HQA)
OAG/MFCU
DFS/PAF
Processes to monitor, detect, or investigate fraud after an instance
PROCESSES TO RECOVER provider health
1 - Provider claim adjustments. (AHCA Medicaid
Area Field Offices)
11 - Criminal prosecutions.
(OAG Statewide
Prosecutor)
(US Attorneys
& Florida SAs)
2 - Medicaid provider self-audits. (AHCA)
AND ABUSE RECOVERY
PROCESSES
10 - Recipient collections.
(DCF Benefit Recovery)
3 - Monitoring and regulation of providers dealing with disabled. (APD)
RECOVERY
5 - Medicaid policy dev., enrollments, and provider ed. (AHCA Dir.’s Office,
MCM & Area Offices)
Legend
AHCA
DCF
DOH
APD
OAG/MFCU
DFS/PAF
9 - Provider collections.
(APD Field Offices)
8 - Provider collections.
(AHCA Finance and
Accounting) (DOH support)
7 - Litigation and settlements. (OAG/MFCU)
4 - Provider sanctioning.
(AHCA Director’s Office and MPI)
5 - Litigation and support.
(AHCA General Counsel’s
Office & TPL Vendor)
Processes to avoid fraud and/or abuse prior to payments
6 - Recipient sanctions. (DCF IG)
Legend
AHCA
DCF
DOH
APD
OAG/MFCU
Strike Force Final Report 35
Processes to recover funds and other resources lost as a result of fraud and/or abuse
DFS/PAF

As a result of this project, the Mapping Committee identified the ACCESS system as the next targeted process area to be mapped. It was selected by the
Committee because, as the entry point for any person applying for Medicaid or public assistance, it was considered to be a most vulnerable area.
Strike Force Recommendation: Increased emphasis on prevention is needed to avoid the need to “pay and chase.” Specifically, it was recommended
ACCESS processes be mapped to identify points where enhancements can be made to prevent fraud.
With support from DFS mapping staff, as well as assistance and collaboration from DCF staff, mapping of the ACCESS system was launched in 2013. A number of meetings, with staff as well as trainers, were held and it was ultimately determined that a vendor for DCF could prepare the desired maps as part of the Medicaid Eligibility System (MES) Project which will be incorporated into enhancements to ACCESS. Maps of the existing system are now available and future enhancements are in the process of being mapped.
Strike Force Recommendation: Increase leveraging of resources to minimize costs to the state. In particular, it was recommended that recommendations that have been raised to the
Strike Force that require additional budget should be presented to the Legislature when there are cost savings that can be achieved through improved efficiencies.
Legislative and Policy Committee.
The Strike Force then established a Legislative and Policy Committee in August 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this Committee were:
1. To develop legislative platforms that will support the implementation of Strike Force initiatives and strategies.
2. To review initiatives of other states that address
Medicaid and public assistance fraud.
3. To make proposals to the Strike Force regarding innovative policy initiatives.
This committee met regularly to share potential legislative and policy concerns. Particular attention was given to supporting those issues and budget recommendations that had the greatest potential to improve efficiencies and save money.
In the past year, this committee was expanded to include participation from the Office for Early
Learning (OEL) and DEO.
Technology Committee.
The Strike Force also established a Technology Committee in August 2011 with representation from each of the state agencies that hold seats on the Strike Force. The purposes of this Committee were:
1. To interact with the Interagency Technology working group to guide policy regarding the implementation of technology solutions throughout the Medicaid and public assistance service systems.
2. Provide advice/guidance on specific technology options.
Strike Force Recommendation: Funding for advanced detection systems using data mining techniques to identify fraud is needed. Specific needs that were identified included funding to implement
1) Identity Verification technology; 2) Asset
Verification technology; 3) AHCA’s Data connectivity plan, 4) the Medicaid Eligibility System (MES)
Replacement; and 5)other information systems that track public assistance benefit programs. Any and all opportunities for better access to data, and better data matching are needed. In addition, agencies need to make better use of available data. In particular, it was recommended that a feasibility study on the best value approach for the state to modernize its current integrated eligibility system (IES)- Florida
Online Recipient Integrated Data Access (known as
FLORIDA) be done.
This committee proved to be an invaluable vehicle for information sharing among the Chief Information
Officers of the Strike Force member agencies. They exchanged information on tools being used or that could be used to advance efforts to fight fraud in
Medicaid and public assistance programs. In 2012, the Committee drafted and the Strike Force issued a Request for Information (RFI) on anti-fraud technology and related solutions available from the private sector. The RFI was issued September 18,
2012, responses to vendor questions were provided
October 16, 2012, and the deadline for submitting responses was November 6, 2012. The Strike Force received 42 responses from entities around the
36 Strike Force Final Report

country. Those responses were varied and included offers of databases, analytics, expert consultants, identity verification technologies and others.
In addition, the Division of Information Systems at DFS set up a secure on-line system to allow
Strike Force members and their staff to review the proprietary versions of the responses. There are also non-proprietary versions available for public release. The system provides the ability to view each individual response, search an individual response or all responses and submit comments that can also be viewed within the system.
The Strike Force received numerous public records requests from technology firms which can facilitate cross-pollination of the components described in the responses. There has been no other single source identified where such information can be found.
The Technology Committee generated one of the most overarching recommendations for the Strike Force: secure more advanced detection systems and make better use of data. There are numerous examples of how this recommendation has been implemented:
• The use of link analysis by AHCA (pages 11 and
25);
• The implementation of Customer Authentication by DCF (page 18);
• The implementation of a new asset verification system by DCF (page 19);
• The implementation of a new MES (page 19);
• The implementation of cutting edge anti-fraud analytics by the new EBT vendor (page 19);
• Increased data matching by DCF through the
Public Assistance Reporting Information System
(PARIS) (page 19);
• The implementation of the DOC auto closure project by DCF (page 18);
• The continued implementation of AHCA’s
Strategic Plan for Data Connectivity (page 23);
• The replacement of AHCA’s legacy case tracking system (page 21);
• The implementation of the Public Benefits
Integrity Data Analytics and Information
Sharing Initiative by AHCA (page 24); and
• The expansion of MFCU’s data mining activities to include the use of a cloud platform containing advanced data detection (page 28).
All of these solutions address one of the three recommendations that were presented in the Fraud
Rate Study report prepared by the ERS Group (page
38): conduct more rigorous screening using advanced detection systems. Additional enhancements to fraud prevention, detection and recoupment of funds may be made from other technology advancements, as described below.
In 2012, AHCA also added a new tool to their existing set of detection tools – predictive modeling software.
This technology helps identify data anomalies not found using traditional detection tools and allows the detection of outlier providers based on aberrant aggregate utilization compared to peer Medicaid providers. This new software-based approach is an enhanced capability because it facilitates fraud detection in Medicaid claims by evaluating every claim in the context of another claim to determine the probability of whether the claimed Medicaid encounter actually took place and, if so, evaluating whether the claim was accurately represented.
In 2013, AHCA established File Transfer Protocol
(FTP) sites to enable data sharing between MPI and MFCU. This will greatly enhance exchanges of information between these two enforcement offices.
Data sharing will also be enhanced through the implementation of the Public Benefits Integrity Data
Analytics and Information Sharing Initiative by
AHCA, previously discussed.
One area of concern identified by the Mapping
Committee was the need to scrutinize ACCESS as the entry portal for public assistance applicants. This subsequently raised discussion of the opportunity to revise components of the FLORIDA system which provides the platform for DCF’s public assistance programs.
The 2012 Legislature appropriated funds and directed
AHCA to contract for a feasibility study. Gartner, a technology research firm, was selected to conduct the study. The purpose of the study was to:
• Identify the strengths, gaps and risks regarding the state’s readiness to move forward with an
Integrated Eligibility System (IES);
• Provide action oriented recommendations to ensure that the state has in place the essential resources, standards and best practices to support the feasibility study, alternatives analysis and to implement the recommended best value alternative for the IES; and
Strike Force Final Report 37

• Establish a foundation for identifying the criteria essential to assess the viability of alternative approaches to the modernization of the state’s IES.
The most viable options identified by the study, which was completed in December of 2012, were:
Option 1: All MODIFIED ADJUSTED
GROSS INCOME (MAGI) - based eligibility rules to be implemented in a Business Rules
Management System would be added to the existing FLORIDA/ACCESS System.
Option 2: Implement Option 1, and further add and implement the rules related to the existing non-MAGI Medicaid Programs, in addition to the Patient Protection and
Affordable Care Act (PPACA) MAGI, in the
Business Rules Management System that is added to the existing FLORIDA/ACCESS
System.
Fraud Rate Study.
In 2011, the Strike Force contracted with ERS Group to ascertain the extent of fraud in applications for assistance to the Florida
SNAP program. The scope of work was to 1) review information on metrics and methodologies used to measure fraud, waste, and abuse in government food and nutrition or other public assistance programs, 2) to design and implement a methodology to provide the Strike Force with an estimate of the amount of fraud, waste and abuse leading to overpayments in the Florida Food Assistance Program, also known as SNAP, and to 3) implement that methodology to ascertain the extent of fraud in the program. For the purposes of this analysis, fraud was defined as an intentional deception or misrepresentation made by a person on their public assistance application that resulted in some unauthorized benefit.
At ERS Group’s request, DCF selected a random sample of 545 payments from the universe of all payments made during the three month period from May 2011 through July 2011. The sample data provided information on the recipient, including but not limited to personal identifying information, residence, income, expenses and that month’s benefit amount. ERS Group also received information on household composition, including but not limited to personally identifying information on all individuals listed as being in the household, their relationship to the recipient, their employment status as of the last eligibility review and recorded income contributions.
This information was then provided to DPAF, where in conjunction with DCF, investigators examined the recipients and their applications to determine whether or not the sampled payments involved any fraud, waste or abuse. These investigations included verifying household composition, income and identity, as well as checking a number of different databases to ensure the applicants were legitimate.
The findings in the report were that the estimate of the incidence of fraud in applications to the Florida
SNAP program is 7.5 percent and the estimated overall overpayment amount was between three and four percent. This measure will provide a baseline which can be compared to future measures to evaluate progress being made in fighting fraud in the Florida
SNAP program.
Intergovernmental Coordination and Collaboration.
One important role for the Strike Force to serve was to facilitate intergovernmental coordination and collaboration. Responses to a survey, conducted in June 2012, among the Strike Force members indicated that this role was being accomplished.
One comment stated, “the Strike Force approach facilitates use of all the tools available to each agency in a coordinated and cohesive manner to maximize results.” In fact, continued Interagency Coordination and Communication was ranked as the number three priority activity for the Strike Force to continue.
The following were included among the most important/significant accomplishments of the Strike
Force since it first organized.
The Strike Force enhanced communications between the Medicaid fraud and abuse programs and the other public assistance fraud and abuse programs through their regular meetings, as well as committee meetings. As a result, information sharing increased among agencies and law enforcement entities tasked with rooting out public assistance and Medicaid fraud in Florida. Unfortunately scheduling meetings was problematic since agency heads were restricted from designating representatives to attend on their behalf. The 2013 Legislature offered a remedy to this by amending the statute to allow Strike Force members to designate alternative attendees. This was accomplished through the passage of HB 939.
Strike Force Recommendation: Allow Strike Force members to name designees to serve in their place for
Strike Force meetings.
38 Strike Force Final Report

The Strike Force facilitated better coordination of efforts between state agencies. Since agencies were communicating more regularly through Strike Force and committee meetings, agencies were more aware of the efforts of others so that collaboration and coordination was easier. It also became evident that agencies were routinely prioritizing the “hot spots” of fraud activity for reviews and investigations.
Strike Force Recommendation: Identify high volume areas in the state where Medicaid and/or public assistance fraud is occurring, organize relevant agencies to carry out targeted enforcement initiatives and develop enforcement operational plans to launch prioritized enforcement and deterrent initiatives.
The Strike Force has served as a catalyst for nurturing communication and collaboration between agencies.
One way in which the Strike Force has done this is by making referrals to appropriate agencies for specific training needs identified by local law enforcement.
Strike Force Recommendation: Educate local law enforcement agencies across the state on recognizing things that may be criminal in nature or may be fraud, as well as models for investigating and enforcing relevant laws.
This has also been accomplished through two other means: the annual SLEB Conferences (previously discussed) and by way of technical bulletins released through the Florida Fusion Center, operated by
FDLE. Investigation and prosecution models have been presented at the annual SLEB conference for two years. Florida Fusion Center bulletins are developed specifically to educate law enforcement agency personnel of fraud-related issues involving SNAP benefits and EBT cards.
Policy Conference.
In the past year, the Strike Force worked with the FSU Center for Insurance Research to present a policy conference on insurance fraud.
This conference was held on October 18, 2013, in
Tallahassee.
The conference was intended to provide some general background information and then touch on current trends in hopes of facilitating discussion toward more focused topics. The panels of presenters included one on the current state of fraud in the Medicaid health care program, workers’ compensation insurance and the automobile insurance industry. This was followed by a keynote address by Dr. Richard Derrig on the
Massachusetts Community Insurance Fraud initiative, focused on automobile insurance fraud, where it was noted that a large volume of claims were coming from one town. Their investigation into this identified an organized ring of chiropractors and physical therapists.
After they aggressively pursued the “kingpins” of the operation, all the activity disappeared and claims declined substantially. Two other panels of presenters addressed 1) emerging issues and 2) behavioral approaches to dealing with fraud.
The conference was attended by approximately 100 people, including representatives from insurance carriers, regulatory agencies and academia. The conference received very positive feedback and has already started to encourage research. In addition, there has been tremendous support for holding another conference. The Center for Insurance Research and the
Strike Force will work together during the remainder of the Strike Force term to ensure that a follow up conference can be held in the future.
Strike Force Recommendation: Offer enhanced antifraud training opportunities and workshops involving both law enforcement and regulatory personnel within Florida to build collaborative, multiagency efforts to suppress emerging fraud trends.
Public Awareness Activities.
Strike Force staff routinely worked through the DFS public information office to facilitate joint press conferences between member agencies to announce specific initiatives.
Individual agencies have also issued press releases specific to the functions of their agency. Collectively,
Strike Force member agencies have issued at least
123 press releases addressing Medicaid and public assistance fraud prevention measures and enforcement operations.
Strike Force Recommendation: As part of the overall efforts to reduce Medicaid and public assistance fraud, the Strike Force needs to more aggressively pursue relationships with the media and keep them informed of activities and outcomes from the Strike
Force and member agencies. In particular, it was recommended that this effort needs to entail public awareness of the impact of perpetrators on lawabiding citizens and outreach to community groups, organizations and entities to engage their assistance in efforts to educate the public on the impact of
Medicaid and public assistance fraud on law-abiding citizens.
Strike Force Final Report 39

Strike Force staff worked with the Tallahassee Police
Department (TPD) to gain familiarity with the ease of creating public awareness messages cost-effectively.
TPD’s public information officer creates messages on an iPad and then they are posted to the TPD website and other internet locations. Strike Force staff worked with the DFS communications staff and DPAF to create some public awareness video clips to aid in public assistance fraud prevention efforts and asked the Strike Force to authorize their dissemination.
Segments were developed that addressed the general public, EBT retailers and SNAP recipients. The clips had voice-overs in English, Spanish and Creole and ran less than a minute. These were distributed to
Strike Force member agencies, as well as participants at the July 2013 SLEB conference.
40 Strike Force Final Report

THE FRAMEWORK
At the final meeting of the Medicaid and Public
Assistance Fraud Strike Force (Strike Force) two presentations were scheduled to provide a framework at the federal level, within which fraud fighting efforts will be moved forward by the current member agencies.
Patient Protection and Affordable Care Act.
The
Patient Protection and Affordable Care Act (PPACA) was signed into law by the President on March 23,
2010. This is the most significant regulatory overhaul of the U.S. healthcare system since the passage of
Medicare and Medicaid in 1965. The legislation contains provisions that were included to help states fight fraud in Medicaid. Most of these provisions under the PPACA were actually already in place in
Florida as a result of the enactment of Senate Bill (SB)
1986.
Two matters that PPACA covered that were not addressed by SB 1986 were that it extended the timeframe within which Medicaid overpayments had to be refunded to the Center for Medicare and
Medicaid Services (CMS) from 60 days to one year.
In addition, Medicaid Program Integrity (MPI) units are now required to engage Medicaid Recovery
Audit Contractors in all states, unless a waiver has been approved. Florida has a waiver because of the move to statewide managed care. However, since the
Florida Medicaid population will always have people on fee-for-services while they wait to be assigned to a managed care provider, the Agency for Health Care
Administration (AHCA) is going to pursue securing services of Medicaid Recovery Audit Contractors on a contingent fee basis. This could be a legislative issue for which other agencies’ support would be helpful.
2014 Farm Bill.
More recently Congress enacted the 2014 reauthorization of the Farm Bill. Certain provisions will impact Florida’s Supplemental
Nutrition Assistance Program (SNAP). Some of them have already been addressed by Florida. There are others which must be implemented immediately.
Strike Force Final Report 41
Section 4002, Subsection 1 allows for manual vouchers to be used or accepted as payment in Electronic
Benefit Transfer (EBT) systems in disasters or in the event of an EBT system failure. Since Florida is prone to hurricanes, this will present some challenges for
Florida.
Section 4013 requires States to verify applicant wage data through the National Directory of New Hires to determine eligibility and the correct amount of SNAP benefits at the time of certification. States will need to enter into contracts with the Department of Health and Human Services (HHS) to use the National
Directory of New Hires. This is an unfunded mandate.
Florida piloted and subsequently discontinued this because it was expensive and not as accurate as resources we currently use. A waiver of this requirement should be sought.
Section 4019 changes the Quality Control tolerance level from $50 to $37. This is especially relevant for
Florida who ranked third in the nation last year and received a performance bonus as a result. Florida has historically done well in preventing small errors at the $50 standard, but a reduction in the threshold in a state with the large SNAP population that Florida has could impact Florida’s performance and reduce opportunities for bonuses.
Section 4021 requires high performance bonuses to be used only for SNAP expenses (i.e., technology, improvements in administration and distribution, actions to prevent fraud, waste and abuse, etc.). Unless the federal government mandates that funds be used for other than ongoing operations and maintenance, this will probably result in a reduction in state funding that corresponds to the amount offered in a bonus.
Other provisions are not to be implemented until
Federal Rulemaking has been completed.
Section 4002 provides that, in order to meet SNAP retailer eligibility criteria A, which currently requires

stocking perishable items in two staple food categories and stocking three varieties of staple foods in four categories, will now require stocking at least seven varieties of staple foods in each of the four staple food categories and stocking perishable foods in at least three categories. Since the majority of retailer fraud is coming from small retailers rather than big boxes/ grocers, this could reduce retailer fraud.
Section 4008 prohibits anyone convicted of aggravated sexual abuse; murder; sexual exploitation and abuse of children; sexual assault as defined in the
Violence Against Women Act of 1994; or a similar
State law and who is also not in compliance with the terms of their sentence or is a fleeing felon from receiving SNAP benefits. Currently, Florida has a lifetime disqualification for anyone convicted of drug trafficking; there are about 14,000 Floridians who are disqualified under this law at this time. This additional disqualification criterion will definitely impact the eligible population in Florida.
Section 4009 provides that any household in which a member receives substantial gambling or lottery winnings (as determined by the United States
Department of Agriculture (USDA)) will immediately lose eligibility for SNAP benefits until they again meet normal income and resource standards. Currently the Department of Children and Families (DCF) intercepts lottery payments to individuals who owe any benefit overpayment to the state and has one person dedicated to this.
Section 4010 allows USDA to require states to decline to issue a replacement EBT card to households who make excessive requests for card replacements unless the households provide an explanation for the loss of the card. (It does provide protections for vulnerable persons.) However, it does not allow state refusal of card replacement to mean denial or limitation of eligibility. Florida has noted multiple replacement card requests in cases involving trafficking in benefits.
DCF is already tracking replacement card information and uses it as part of analysis to detect potential fraud.
There are other provisions that are the responsibility of USDA Food and Nutrition Services (FNS), but could have an impact in Florida.
Section 4011 allows for redemption of benefits through mobile devices. Florida is watching this and considers it dangerous because fraudsters are becoming so technology savvy.
CONTINUING STRIKE FORCE ACTIVITIES
Interagency Coordination.
In the interest of continuing the interagency collaboration that has been enhanced since the Strike Force was created, the following agencies are working toward sustaining strategies including routine meetings, sharing of information and interagency agreements. AHCA has offered to retain lead on coordinating these activities.
Partner agencies currently include:
• The Agency for Health Care Administration
• The Office of the Attorney General
• The Department of Children and Family Services
• The Agency for Persons with Disabilities
• The Department of Elder Affairs
• The Department of Financial Services
• The Department of Health
• The Executive Office of the Governor
• The Department of Transportation
• The Department of Corrections
Recommendations for ongoing collaboration include the following:
1. Maintaining a census of state efforts to address fraud including Medicaid fraud and public assistance fraud in this state, including fraud detection, prevention and prosecution, to identify overlapping missions, maximize existing resources and strengthen current programs.
2. Identifying new methods to enhance multiagency efforts that contribute to achieving the state’s duty to detect and prevent fraud, including Medicaid and public assistance fraud.
3. Identifying continuing methods to implement innovative technologies and data sharing in order to detect and analyze fraud against the state with speed and efficiency.
4. Developing and promoting anti-fraud crime prevention services and educational programs that serve the public.
42 Strike Force Final Report

Legislative and Policy Initiatives.
AHCA will coordinate the interagency activities and continue to research, or provide background information for legislative and policy initiatives. Additional Strike
Force recommendations will be areas of continued focus, including:
Access to the Treasury Offset Program (TOP) to recoup Medicaid overpayments through an offset of income tax is needed.
This will require a change to federal regulations.
There is currently a virtual pilot of expansion of TOP to Medicaid in ten states. Texas reports that they submitted more than 172,000 debts for a test and the estimated recovery for these would be $85 million.
This would be a large potential recovery for Florida but will require involvement of Congress.
Grant Initiatives.
In the future, the Task Force can turn to the Florida Interagency Grant Consortium for support and technical assistance. The Consortium is currently made up of nineteen state agencies. The mission of the group is to “secure maximum funding for the State of Florida through resource sharing, professional networking, dynamic collaboration and problem-solving.” The group works together to facilitate best practices in grant management, and to act as an Inter-Agency resource for State of
Florida employees seeking information about grant availability, eligibility, management and training.
Technology.
Technology initiatives will be left to individual agencies to pursue. However, the ongoing interagency coordination will facilitate multiagency support for those initiatives deemed to be of particular value in fighting fraud, waste and abuse in public assistance programs.
Strike Force Final Report 43

44 Strike Force Final Report

Thank you for the opportunity to present this Final
Report of the Medicaid and Public Assistance Fraud
Strike Force. The report describes the fraud problems our member agencies face; the solutions found, assisted or guided by the Strike Force; and the future direction and risks of Florida’s anti-fraud actions. This
Final Report is the comprehensive documentation of the Strike Force’s history, strategy, efforts and results.
The report will become a main source document for further anti-fraud efforts and study in Florida.
As Executive Director, I have overseen and reviewed the issues before the Strike Force. Four issues in particular stand out as critical to Florida’s future antifraud efforts:
• Interagency cooperation and coordination,
• Identity theft,
• Large scale data analytics (“big data”), and
• HMO/MCO Managed care fraud.
The Strike Force, as seen in the Final Report, demonstrated the value of interagency cooperation and coordination in the fight against fraud in
Florida. With or without the Strike Force, the need for interagency cooperation and coordination is strong and increasing, especially due to the growth of managed care in Medicaid and private health care. The Agency for Health Care Administration’s
Interagency Fraud Working Group is a continuing example of the type of multi-agency coordination committee that is needed in an evolving health care delivery system. All anti-fraud agencies should review their interagency interactions to improve communications, streamline procedures and continue to find new channels for positive coordination.
Identity theft is a key crime, in the sense of unlocking your benefits to the thief and by being a crime underlying and critical to almost all types of fraud schemes. Public benefit regulatory agencies must take specific steps to protect their customers and themselves from identity theft in online applications.
One area of identity theft is potentially devastating to a victim; medical identity theft. If a person’s medical identity is stolen, his or her insurance benefits could be used up to a lifetime limit without the victim’s knowledge. A person may only find out that their health insurance is limited when they arrive at a provider for treatment. Identity theft should continue to be a focus of law enforcement agencies in fighting fraud.
Large scale data analytics, commonly known as “big data,” is a fast growing tool in the fight against fraud.
The work of the Strike Force member agencies has shown that data comparison and cross-matching between governmental databases and far larger private industry consumer databases is very valuable in anti-fraud efforts. For example, critical insights into reported data in online public assistance applications can be gained. State and local agencies should continue to review new developments in data analytics in order to make better use of valuable data already collected by their systems.
The most significant change in the State of Florida’s health care delivery system is the move to Medicaid managed care. Eighteen health management organizations are now overseeing the majority of medical service delivery in Florida Medicaid.
This large scale change is bringing new anti-fraud challenges to our member agencies. Interagency cooperation and coordination is more critical, more needed, in a managed care environment. Fraud in managed care organizations tends to be corporate
Strike Force Final Report 45

based - requiring financial investigation and data analytic and audit skills to detect, investigate and prosecute. These skills may not all be present in a single agency, while the required data can be spread across multiple agencies. Anti-fraud agencies must cooperate and coordinate in complex detection efforts, multi-agency investigations and in supporting litigation and criminal prosecutions for managed care fraud.
The staff of the Strike Force and I wish to express our appreciation for the privilege and honor of helping the citizens of the State of Florida and our member agencies fight fraud. The Strike Force’s accomplishments and planning described in this
Final Report have given Florida’s state and local governments a strong basis of knowledge and cooperation to continue to support anti-fraud actions statewide. The Strike Force was a valuable and meaningful effort for coordination in the fight against fraud in our state and will remain a touchstone of anti-fraud regulation and law enforcement in Florida for the foreseeable future.
Sincerely,
Charles Faircloth
Executive Director
46 Strike Force Final Report

ACCESS – The Automated Community Connection to Economic Self Sufficiency (ACCESS) Program is the eligibility determination arm for food assistance, cash assistance and Medicaid which is housed at the
Florida Department of Children and Families.
AHCA – The Agency for Health Care Administration
(AHCA) is the Florida state agency responsible for the state's Medicaid program, the licensure of the state's health care facilities, and the sharing of health care data through the Florida Center for Health
Information and Policy Analysis.
ALF – An assisted living facility (ALF) is designed to provide personal care services in the least restrictive and most home-like environment. These facilities can range in size from one resident to several hundred and may offer a wide variety of personal and nursing services designed specifically to meet an individual's personal needs.
APD – The Agency for Persons with Disabilities
(APD) is the Florida state agency tasked with serving the needs of Floridians with developmental disabilities. The Agency is responsible for operating the Medicaid Developmental Disabilities waiver programs.
CCEB – The Complex Civil Enforcement Bureau
(CCEB) is a section within the Medicaid Fraud
Control Unit, in the Florida Office of Attorney
General, which investigates and litigates cases that allege violations of the Florida False Claims Act when false claims were submitted to the Florida Medicaid
Program.
CDI – A Cooperative Disability Investigation (CDI) unit is a regional investigative unit developed and coordinated by the United States Social Security
Administration which employs state investigative personnel to conduct disability fraud investigations.
CHD – The Florida Department of Health is comprised of a state health office (central office) in Tallahassee, with statewide responsibilities;
Florida’s 67 county health departments (CHDs); 22
Children’s Medical Services area offices; 12 Medical
Quality Assurance regional offices; nine Disability
Determinations regional offices; and four public health laboratories. Facilities for the CHDs are provided through partnerships with local county governments.
CMS – The Center for Medicare and Medicaid
Services (CMS) is a federal agency within the United
States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer
Medicaid, the State Children's Health Insurance
Program, and health insurance portability standards.
DCF – The Florida Department of Children and Families (DCF) has a mission to protect the vulnerable, promote strong and economically self-sufficient families, and advance personal and family recovery and resiliency. DCF is responsible for providing services within child welfare, domestic violence, substance abuse, mental health, homelessness and other areas.
DD Waiver – The Medicaid Developmental
Disabilities Waiver (DD Waiver) programs are operated by the Florida Agency for Persons with
Disabilities and provide services tailored to meet the specific needs of developmentally disabled persons, which are reimbursable by Medicaid.
DEO – The Department of Economic Opportunity
(DEO) is the Florida state agency responsible for promoting economic opportunities for all Floridians through successful workforce, community and economic development strategies.
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DFS – The Department of Financial Services (DFS) is the Florida state agency responsible for safeguarding the people of Florida and the state's assets through financial accountability, education, advocacy, fire safety and enforcement.
DHS -The United States Department of Homeland
Security (DHS) is the federal agency which is primarily responsible for ensuring a safe, more secure
America, which is resilient against terrorism and other potential threats.
DIF – The Division of Insurance Fraud (DIF) is one of fourteen divisions within the Florida
Department of Financial Services. The Division is the law enforcement arm under the Department that is tasked with serving and safeguarding the public and businesses operating in Florida against acts of insurance fraud and is responsible for investigating all types of insurance fraud.
DJJ - The Department of Juvenile Justice (DJJ) is the Florida state agency with the mission to increase public safety by reducing juvenile delinquency through effective prevention, intervention and treatment services that strengthen families and turn around the lives of troubled youth.
DME - Durable Medical Equipment (DME) is any medical equipment used in the home to aid in a better quality of living.
DMV – The Telephonic Home Health Service Delivery
Monitoring and Verification (DMV) Program is a system used by the Florida Agency for Health Care
Administration to verify delivery and/or receipt of home health care services.
DOC – The Department of Corrections (DOC) is the
Florida state agency that is responsible for promoting safety of the public and offenders by providing security, supervision, and care, offering opportunities for successful re-entry into society and capitalizing on partnerships to continue to improve the quality of life in Florida.
DOH – The Department of Health (DOH) is the state agency responsible for protecting, promoting and improving the health of all people in Florida through integrated state, county and community efforts.
DPAF – The Division of Public Assistance Fraud
(DPAF) is one of fourteen divisions within the
Florida Department of Financial Services and is
48 Strike Force Final Report responsible for safeguarding the public and businesses in Florida against acts of public assistance fraud and the resulting impact those crimes have by enforcing federal and state criminal laws in relation to eligibility for public assistance.
DVR – The Division of Vocational Rehabilitation
(DVR) is housed within the Florida Department of
Education and is a federal-state program that helps people who have physical or mental disabilities get or keep a job.
EBT - Electronic Benefit Transfer (EBT) is an electronic system that allows state welfare departments to issue benefits via a magnetically encoded payment card, similar to a pre-loaded credit card.
E-FORCSE® - The Electronic-Florida Online
Reporting of Controlled Substances Evaluation
(E-FORCSE®) is the name of Florida’s Prescription
Drug Monitoring Program created by the 2009
Florida Legislature in an initiative to encourage safer prescribing of controlled substances and reduce drug abuse and diversion within the state. The purpose of E-FORCSE® was to provide information to guide health care practitioners’ prescribing and dispensing decisions regarding highly abused prescription drugs.
ESO – Issuing an Emergency Suspension Order
(ESO) is an action taken by the Florida Department of Health which suspends a health professional's license as a result of gross negligence, misconduct or malpractice, health care fraud, violations of controlled substance standards, or any conduct that jeopardizes public health, safety or welfare.
FDLE – The Florida Department of Law Enforcement
(FDLE) is a statewide law enforcement agency comprised of investigators and crime laboratory analysts who operate through regional operation centers and whose primary investigative focus is dedicated to multi-jurisdictional, organized criminal groups involved in primarily economic, major drugs, violent and public integrity criminal violations.
FMMIS – The Florida Medicaid Management
Information System (FMMIS) is the information system used to process Florida Medicaid claims and payments to Health Plans, and to produce management information and reports relating to the
Florida Medicaid program. This system is also used to maintain Medicaid eligibility data and provider enrollment data.

FNS – The Food and Nutrition Services (FNS) is an arm of the United States Department of Agriculture which is responsible for administering the nation’s domestic nutrition assistance programs.
FSU - Florida State University (FSU) is one of the state universities in Florida and is located in
Tallahassee, Florida.
FY - An abbreviation used for fiscal year.
HB – An abbreviation that references a legislative bill originally filed in the Florida House of
Representatives as a House Bill (HB).
HEAT - The United States Departments of Health and
Human Services and Justice created the Health Care
Fraud Prevention and Enforcement Action Teams
(HEAT) to gather resources across government to help prevent waste, fraud, and abuse in the Medicare and
Medicaid programs. Two of the nine national HEAT teams are located in Florida.
HHS – The United States Department of Health and
Human Services (HHS) is the federal government's principal agency for protecting the health of all
Americans and providing essential human services.
HMO – A Health Maintenance Organization (HMO) is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities in the
United States and acts as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis.
HMS – The Health Management System (HMS) is the
Florida Department of Health’s practice management system and certified Electronic Health Record in use in the 67 county health departments.
HQA – The Division of Health Quality Assurance
(HQA), within the Florida Agency for Health Care
Administration, regulates forty types of health care service providers through the licensure, certification or registration of more than 46,000 health care facilities and providers and over 80 managed care organizations from which Medicaid recipients may receive services.
HUD – The United States Department of Housing and
Urban Development (HUD) is the federal agency with the mission to create strong, sustainable, inclusive communities and quality affordable homes for all.
IES – An Integrated Eligibility System (IES) is a system that serves more than just individuals enrolling in Medicaid programs. Integrated systems may support Medicaid, Supplemental Nutrition
Assistance Program, and Temporary Assistance to
Needy Families programs, as well as others.
ISU - Investigative Services Units (ISUs) at the Florida
Department of Health investigate complaints against health care practitioners and facilities/establishments regulated by the Department, as well as unlicensed activity complaints.
ITN – In Florida, an Invitation to Negotiate (ITN) is a competitive solicitation, for goods or services, where factors other than price are to be considered in the award determination. These factors may include such things as vendor experience, project plan, design features of the product(s) offered, etc.
MAGI – The Modified Adjusted Gross Income
(MAGI) is found by taking an individual's adjusted gross income and adding back certain items such as foreign income, foreign-housing deductions, studentloan deductions, IRA-contribution deductions and deductions for higher-education costs.
MCO - Managed Care Organizations (MCOs) typically provide a wide range of health services through managed care plans which try to save money by providing preventive health care services to help avoid serious health problems and by contracting with doctors and hospitals in the community to help control the fees they charge.
MCSO – The Manatee County Sheriff ’s Office
(MCSO) is the local county law enforcement agency serving Manatee County, Florida.
MDPD – The Miami-Dade Police Department
(MDPD) is the local joint municipal/county law enforcement agency serving Miami-Dade County,
Florida.
MES – The Medicaid Eligibility System (MES) is the system that accepts applications for and determines eligibility for Medicaid.
MFCU – The Medicaid Fraud Control Unit (MFCU) within the Florida Office of the Attorney General, is the referral point for AHCA when provider cases are determined to entail fraud. MFCU is responsible for investigating and prosecuting providers who intentionally defraud the Medicaid program.
Strike Force Final Report 49

MPI – The Office of Medicaid Program Integrity
(MPI) is housed in the Office of Inspector General at the Florida Agency for Health Care Administration and is responsible for ensuring the integrity of the
Florida Medicaid program. MPI reviews the billing and claims activities of Medicaid recipients and providers to minimize fraudulent activities and program abuses, while also identifying neglect of recipients
MQA – The Bureau of Medical Quality Assurance
(MQA), in the Florida Department of Health, licenses about a million licensees/practitioners in forty different professional groups in Florida, though not all licensees are Medicaid providers.
OAG – The Office of Attorney General (OAG) is
Florida’s agency for the state Attorney General.
OAS – The Office of Audit Services (OAS) in the United States Department of Health and
Human Services conducts independent audits of the Department’s programs and/or grantees and contractors, including state Medicaid agencies, to evaluate their performance in carrying out their responsibilities and provide independent assessments of programs and operations.
OEL - The Office for Early Learning (OEL) within the Florida Department of Education is dedicated to ensuring access, affordability and quality of early learning services for Florida’s children and families.
OI – The Office of Investigations (OI) in the United
States Department of Health and Human Services conducts investigations of fraud and misconduct related to the Department’s programs, operations and beneficiaries.
OIG – The Office of Inspector General (OIG) is an office that is part of departments and independent agencies of the United States federal government as well as some state and local governments. Each office includes an Inspector General and employees charged with identifying, auditing, and investigating fraud, waste, abuse and mismanagement within the parent agency.
OIR – The Office of Insurance Regulation (OIR) is an independent office within the Florida Department of
Financial Services which has primary responsibility for regulation, compliance and enforcement of statutes related to the business of insurance and the monitoring of insurance industry markets.
OPBI – The Office of Public Benefits Integrity (OPBI) is part of the Florida Department of Children and
Families whose primary functions are auditing for data integrity and benefit recovery within the Supplemental
Nutrition Assistance Program and the Temporary
Assistance for Needy Families program.
OPPAGA - The Office of Program Policy Analysis and
Government Accountability (OPPAGA) is an office of the Florida Legislature that provides data, evaluative research and objective analyses to assist legislative budget and policy deliberations. OPPAGA conducts research as directed by state law, the presiding officers or the Joint Legislative Auditing Committee.
PARIS – The Public Assistance Reporting Information
System (PARIS) is a Federal-State partnership which provides all fifty States, D.C., and Puerto Rico detailed information and data to assist them in maintaining program integrity and detecting/ deterring improper public assistance payments.
PBSO – The Palm Beach County Sheriff ’s Office
(PBSO) is the local county law enforcement agency serving Palm Beach County, Florida.
PDMP - A Prescription Drug Monitoring Program
(PDMP) is a statewide electronic database (housed by a specified statewide regulatory, administrative or law enforcement agency) which collects designated data on substances dispensed in the state. The housing agency distributes data from the database to individuals who are authorized under state law to receive the information for purposes of their profession.
PPACA - The Patient Protection and Affordable
Care Act (PPACA) is the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965, with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage and reducing the costs of healthcare for individuals and the government.
It introduced a number of mechanisms—including mandates, subsidies, and insurance exchanges—meant to increase coverage and affordability.
RDESF – The Regional Drug Enforcement Strike
Forces (RDESF) are seven regional task forces in
Florida, organized in 2011, to pursue investigation and prosecution of illegal prescription drug operations (pill mills).
50 Strike Force Final Report

SB - An abbreviation that references a legislative bill originally filed in the Florida Senate as a Senate Bill
(SB).
SLEB – A State Law Enforcement Bureau (SLEB) is a state entity that has been designated by the United
States Department of Agriculture to serve as the liaison between local and state agencies and USDA in carrying out targeted investigations of electronic
Supplemental Nutrition Assistance Program benefit trafficking.
SNAP – The Supplemental Nutrition Assistance
Program (SNAP) is the largest program in the domestic hunger safety net that offers nutrition assistance to millions of eligible, low-income individuals and families and provides economic benefits to communities. The Food and Nutrition
Service works with state agencies, nutrition educators, and neighborhood and faith-based organizations to ensure that those eligible for nutrition assistance can make informed decisions about applying for the program and can access benefits.
SPM – The Santrax Payor Management (SPM) system is a product of Sandata which leverages the integration of the plan-of-care, authorizations, eligible participants, and home care provider agencies
(including self-directed caregivers) to ensure care is delivered in the home setting as authorized.
SSA – The United States Social Security
Administration (SSA) is the federal agency responsible for administration of the social security program.
SSN – A social security number (SSN) is a unique identifier assigned by the Social Security
Administration for the purpose of tracking the individual’s eligibility for and level of benefits.
Strike Force – The Medicaid and Public Assistance
Fraud Strike Force (Strike Force) was created within the Department of Financial Services to oversee and coordinate state and local efforts to eliminate
Medicaid and public assistance fraud and to recover state and federal funds.
TANF – The Temporary Assistance for Needy
Families (TANF) program is one of the United States of America's federal assistance programs which provides cash assistance to indigent American families with dependent children through the United States
Department of Health and Human Services.
TOP – The Treasury Offset Program (TOP) is a federal program designed to collect various delinquent non-tax debts (including overdue child support payments) by offsetting certain federal payments disbursed by Financial Management
Services (within the United States Department of the
Treasury) to individuals holding the debt.
TPD – The Tallahassee Police Department (TPD) is the local municipal law enforcement agency serving
Tallahassee, Florida.
USDA – The United States Department of Agriculture
(USDA) is the United States federal agency responsible for developing and executing federal government policy on farming, agriculture, forestry, and food and which strives to meet the needs of farmers and ranchers, promote agricultural trade and production, work to assure food safety, protect natural resources, foster rural communities and end hunger in the United States and abroad.
WIC – The Women, Infants and Children (WIC) program is a federal assistance program of the Food and Nutrition Service of the United States Department of Agriculture for healthcare and nutrition of lowincome pregnant women, breastfeeding women, and infants and children under the age of five.
Strike Force Final Report 51