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Federal and State Program Integrity in Florida

The Department of Legal Affair’s Medicaid Fraud Control Unit,1 the Department of Health,2 the Agency for Health Care Administration,3 the Department of Financial Services’ Medicaid and Public Assistance Fraud Strike Force4 are authorized to investigate all allegations of Medicaid fraud. Health care providers must permit government agencies to access all Medicaid-related information and records.5 Prior to providing services to a patient, a licensed health care facility or provider must inform the patient or the patient’s family or representative of the right to report complaints, abusive, neglectful, or exploitative practices, or Medicaid fraud.6

The purpose of the Florida False Claims Act is to deter individuals from filing false claims to the state government.7 Any person who files a false claim for payment to the Florida government is subject for a civil penalty between $5,500 and $11,000.8 The Department of Legal Affairs is responsible for investigating an allegation that an individual submitted a false claim.9 The Department of Legal Affairs has the primary responsibility to prosecute individuals who file false claims.10 If the Department of Legal Affairs prosecutes an individual who filed false claims and succeeds in recovering damages, the person who reported the false claims is entitled to 15-25% of the damages.11 The Legal Affairs Revolving Trust Fund is established within the State Treasury to fund investigations, prosecutions and enforcement by the Attorney General of the Florida False Claims Act.12

A person commits a fraudulent insurance act if he presents a false or fraudulent claim for payment to a health insurer.13 The Department of Financial Services or its Division of Insurance Fraud is authorized to investigate insurance fraud and collect evidence.14

Health care providers are prohibited from accepting or charging a fee, kickback, or other compensation with another health care provider for patient referrals.15 A home health agency may face disciplinary sanctions for a pattern of billing the Medicaid program for services to Medicaid recipients which are medically unnecessary.16 An individual who fraudulently obtains goods, products, or services from a health care provider is guilty of a misdemeanor of the 2nd degree.17

 

Footnotes

  • 1.   Florida Statutes §§ 16.59; 112.3187; 409.9203
  • 2.   Florida Statutes § 391.095
  • 3.   Florida Statutes §§ 408.08; 409.913; 409.963; 409.966; 465.188
  • 4. Florida Statutes §§ 624.351; 624.352
  • 5. Florida Statutes § 409.907
  • 6.   Florida Statutes § 408.810
  • 7.   Florida Statutes §§ 68.081; 409.9131; 409.920; 409.9201
  • 8.   Florida Statutes § 68.082
  • 9.   Florida Statutes § 68.083
  • 10.   Florida Statutes § 68.084
  • 11.   Florida Statutes § 68.085
  • 12.  Florida Statutes § 16.53
  • 13.  Florida Statutes §§ 409.91212; 626.989; 626.9891; 626.9892; 641.3915; 817.234
  • 14. Florida Statutes §§ 636.206; 641.418
  • 15.   Florida Statutes §§ 390.025; 395.0185; 400.17; 400.176; 400.474; 400.518; 400.957; 456.052; 456.053; 456.054; 456.0635; 458.327; 459.013; 459.015; 462.14; 463.016; 465.185; 466.0235; 468.365; 483.245; 483.825; 486.125; 490.009; 491.009; 817.505;
  • 16.   Florida Statutes § 400.474
  • 17. Florida Statutes § 817.50

 

Federal and State Program Integrity in Florida

Subtopic Statute/Regulation Description
Federal and State Program Integrity F.S.A. § 456.057 Ownership and control of patient records; report or copies of records to be furnished  This section refers to “record owners” as any...
Florida Administrative Code § 64B16-30.001 “Disciplinary guidelines; range of penalties; aggravating and mitigating circumstances under the Department of Health regulations” The...
Florida Administrative Code § 64B18-14.002 “Disciplinary guidelines under the Department of Health regulations” The Board of Podiatric Medicine may discipline and fine podiatrists...
Florida Administrative Code § 64B19-17.002 “Disciplinary guidelines under the Department of Health regulations” The Board of Psychology may discipline and fine psychologists for a...
Florida Administrative Code § 64B27-2.001 “Disciplinary guidelines under the Department of Health regulations”   The Department of Health must impose disciplinary...
Florida Administrative Code § 64B32-5.001 “Disciplinary guidelines under the Department of Health regulations” The Board of Respiratory Care may discipline and fine respiratory...
Florida Administrative Code § 64B8-30.015 “Disciplinary guidelines under the Department of Health regulations” The Board of Medicine may discipline and fine a physician assistant...
Florida Administrative Code § 64B8-8.001 “Disciplinary guidelines under the Department of Health regulations” The Board of Medicine may fine or suspend, deny, place on probation...
Florida Administrative Code §59A-7.037 “Rebates prohibited- penalties under the Agency for Health Care Administration regulations”   Clinical laboratories may not pay...
Florida Statutes § 112.3187 “Adverse action against employee for disclosing information of specified nature prohibited; employee remedy and relief under the Whistle-blower...
Florida Statutes § 16.53 “Legal Affairs Revolving Trust Fund under the executive branch law” The Legal Affairs Revolving Trust Fund is established within the...
Florida Statutes § 16.59 “Medicaid fraud control under the executive branch law” The Department of Legal Affair’s Medicaid Fraud Control Unit is authorized...
Florida Statutes § 390.025 “Abortion referral or counseling agencies; penalties under the public health law” An abortion referral or counseling agency may not...
Florida Statutes § 391.095 “Program integrity under the Children’s Medical Services Act” The Department of Health must operate a system to oversee the...
Florida Statutes § 395.0185 “Rebates prohibited; penalties under the public health law” A hospital may not pay or receive any commission, bonus, kickback, or rebate...
Florida Statutes § 400.17 “Bribes, kickbacks, certain solicitations prohibited under the public health law” Any person that accepts a bribe or kickback for a...
Florida Statutes § 400.176 “Rebates prohibited; penalties under the public health law” A nursing home is prohibited from paying or receiving any commission, bonus,...
Florida Statutes § 400.474 “Administrative penalties under the public health law” A home health agency may face disciplinary sanctions for the following acts:...
Florida Statutes § 400.518 “Prohibited referrals to home health agencies under the public health law” A hospital or ambulatory surgical center that has a financial...
Florida Statutes § 400.957 “Prohibited acts under the public health law” Home medical equipment providers must comply with state and federal laws regarding...
Florida Statutes § 408.08 “Inspections and audits; violations; penalties; fines; enforcement under the public health law” The Agency for Health Care Administration...
Florida Statutes § 408.810 “Minimum licensure requirements under the Health Care Licensing Procedures Act” Prior to providing services to a patient, a licensed...
Florida Statutes § 409.902 “Designated single state agency; payment requirements; program title; release of medical records under the social welfare law” The Agency...
Florida Statutes § 409.907 “Medicaid provider agreements under the social welfare law” Health care providers participating in the Medicaid program must comply with...
Florida Statutes § 409.91212 “Medicaid managed care fraud under the social welfare law” Each Medicaid managed care plan must adopt an anti-fraud plan to detect and...
Florida Statutes § 409.913 “Oversight of the integrity of the Medicaid program under the social welfare law” The Agency for Health Care Administration must oversee...
Florida Statutes § 409.9131 “Special provisions relating to integrity of the Medicaid program under the social welfare law” Physicians are subject to Medicaid fraud...
Florida Statutes § 409.920 “Medicaid provider fraud under the social welfare law” A health care provider that participates in Medicaid may not: File claims with...
Florida Statutes § 409.9201 “Medicaid fraud under the social welfare law” A person who sells or attempts to sell a prescription drug that was paid by Medicaid is...
Florida Statutes § 409.9203 “Rewards for reporting Medicaid fraud under the social welfare law” The Department of Law Enforcement or the Medicaid Fraud Unit may pay...
Florida Statutes § 409.963 “Single state agency under the social welfare law” The Agency for Health Care Administration must ensure that each Medicaid recipient...
Florida Statutes § 409.966 “Eligible plans; selection under the social welfare law” The Agency for Health Care Administration must compile and publish a databook...
Florida Statutes § 456.052 “Disclosure of financial interest by production under the regulations and occupations law” A health care provider must not refer a...
Florida Statutes § 456.053 “Financial arrangements between referring health care providers and providers of health care under the Patient Self-Referral Act of 1992...
Florida Statutes § 456.054 “Kickbacks prohibited under the regulation of professions and occupations law” A health care provider may not offer, pay, or receive a...
Florida Statutes § 456.0635 “Health care fraud; disqualification for license, certificate, or registration under the regulation of professions and occupations law” A...
Florida Statutes § 458.327 “Penalty for violations under the regulation of professions and occupations law” A physician is guilty of a felony of the third degree...
Florida Statutes § 459.013 “Penalty for violations under the regulation of professions and occupations law” Each of the following acts constitutes a felony of the...
Florida Statutes § 459.015 “Grounds for disciplinary action; action by the board and department under the regulation of professions and occupations law” The Board...
Florida Statutes § 462.14 “Grounds for disciplinary action; action by the department under the regulation of professions and occupations law” Naturopathic...
Florida Statutes § 463.016 “Grounds for disciplinary action; action by the board under the Optometry Practice Act”  Optometrists may be denied a license or...
Florida Statutes § 465.185 “Rebates prohibited; penalties under the Florida Pharmacy Act” Pharmacists are prohibited from paying or receiving any commission, bonus...
Florida Statutes § 465.188 “Medicaid audits of pharmacies under the Florida Pharmacy Act” The Agency for Health Care Administration may annually audit a licensed...
Florida Statutes § 466.0235 “Dental charting under the regulation of professions and occupations law” All referrals made during the provision of dental charting...
Florida Statutes § 468.365 “Disciplinary grounds and actions under the regulation of professions and occupations law” Respiratory therapists may be denied a license...
Florida Statutes § 483.245 “Rebates prohibited; penalties under the regulation of professions and occupations law” Clinical laboratories are prohibited from paying...
Florida Statutes § 483.825 “Grounds for disciplinary action under the regulation of professions and occupations law” Clinical laboratory personnel may be denied a...
Florida Statutes § 486.125 “Refusal, revocation, or suspension of license; administrative fines and other disciplinary measures under the regulation of professions and...
Florida Statutes § 490.009 “Discipline under the regulation of professions and occupations law” The Board Psychology may deny a license or impose disciplinary...
Florida Statutes § 491.009 “Discipline under the regulation of professions and occupations law” The Board of Clinical Social Work may deny a license or impose...
Florida Statutes § 624.351 “Medicaid and public assistance fraud strike force under the insurance law” The Medicaid and Public Assistance Fraud Strike Force is...
Florida Statutes § 624.352 “Interagency agreements to detect and deter Medicaid and public assistance fraud under the insurance law” The Chief Financial Officer of...
Florida Statutes § 626.989 “Investigation by department or Division of Insurance Fraud; compliance; immunity; confidential information; reports to division; division...
Florida Statutes § 626.9891 “Insurer anti-fraud investigative units; reporting requirements; penalties for noncompliance under Unfair Insurance Trade Practices Act”...
Florida Statutes § 626.9892 “Anti-fraud reward program; reporting of insurance fraud under Unfair Insurance Trade Practices Act” The Office of Insurance Regulation...
Florida Statutes § 636.206 “Examination and investigations under the insurance law” The Office of Insurance Regulation may examine or investigate the business and...
Florida Statutes § 641.3915 “Health maintenance organization anti-fraud plans and investigative units under the Health Maintenance Organization Act” A health...
Florida Statutes § 641.418 “Examination of prepaid health clinic by the office under the Prepaid Health Clinic Act” The Office of Insurance Regulation must examine...
Florida Statutes § 68.081 “Florida False Claims Act; short title; purpose under the Florida False Claims Act” The purpose of the Florida False Claims Act is to...
Florida Statutes § 68.082 False claims against the state; definitions; liability under the Florida False Claims Act” Any person who files a false claim for payment to...
Florida Statutes § 68.083 “Civil actions for false claims liability under the civil practice and procedure law” The Department of Legal Affairs is responsible for...
Florida Statutes § 68.084 “Rights of the parties in civil actions under the Florida False Claims Act” The Department of Legal Affairs has the primary...
Florida Statutes § 68.085 “Awards to plaintiffs bringing action under the Florida False Claims Act” If the Department of Legal Affairs prosecutes an individual who...
Florida Statutes § 817.234 “False and fraudulent insurance claims under the crimes law” A person who submits a false claim to a health insurer is guilty of a felony...
Florida Statutes § 817.50 “Fraudulently obtaining goods, services, etc., from a health care provider under the crimes law” An individual who fraudulently obtains...
Florida Statutes § 817.505 “Patient brokering prohibited; exceptions; penalties under the crimes law” It is unlawful for a health care provider or facility to offer...