Increased federal scrutiny of Medicaid program integrity has been announced, with Florida included in a series of recent inquiries led by the Centers for Medicare & Medicaid Services (CMS). CMS Administrator Mehmet Oz sent a request to Florida officials seeking information on how the state identifies, prevents, and addresses fraud, waste, and abuse within its Medicaid program.
Florida is one of several states that have recently received similar requests. Earlier inquiries were directed to New York, Minnesota, Maine, and California. In a related congressional effort, additional states—including Colorado, Massachusetts, Nebraska, Oregon, Pennsylvania, Vermont, and Washington—have also been asked to provide information about their Medicaid oversight processes.
The request to Florida includes questions related to program integrity, including how potential fraud is detected, investigated, and resolved. CMS has recently highlighted concerns involving durable medical equipment, prosthetics, and orthotics suppliers under Medicare and has noted that similar vulnerabilities may exist within Medicaid. A temporary pause on new Medicare enrollments for certain suppliers was implemented as part of those efforts.
Federal officials have also referenced prior enforcement actions involving alleged fraud in areas such as home-based services, nonemergency medical transportation, and behavioral health services. State officials, including Governor Ron DeSantis and Attorney General James Uthmeier, have indicated that Florida is working with federal agencies and have cited recent Medicaid fraud-related arrests.
These developments coincide with a broader federal initiative focused on program integrity. An executive order issued by President Donald Trump established a task force on fraud across public benefit programs, led by Vice President JD Vance.
Florida officials have been given a set timeframe to respond to CMS with details on their program integrity efforts.
Compliance Perspective
Issue
Increased federal scrutiny of Medicaid program integrity has led to additional oversight of state programs, including recent inquiries directed to Florida. CMS has requested information from multiple states regarding how they identify, prevent, and address fraud, waste, and abuse. These efforts follow ongoing concerns related to improper billing, program vulnerabilities, and enforcement actions across both Medicare and Medicaid. As federal and state agencies continue to evaluate program integrity, providers are expected to maintain effective compliance frameworks to mitigate risk and ensure adherence to regulatory requirements.
Discussion Points
- Review, and update if necessary, policies and procedures related to Medicaid billing, documentation, and program integrity. Policies should clearly define processes for identifying and reporting potential fraud, waste, and abuse, and should be reviewed at least annually or when regulatory changes occur. Some organizations utilize external consultants to perform targeted reviews or mock surveys to help identify gaps and strengthen internal controls.
- Provide education and training to staff on compliance requirements, documentation standards, and recognizing potential fraud indicators. Training should occur upon hire and at least annually, with additional focus for staff involved in billing, coding, and clinical documentation. Med‑Net Academy offers the course Origin of Fraud, which covers the role of the Office of Inspector General (OIG) and the DOJ, Medicaid fraud control units and Medicare and DOJ fraud strike forces, federal monitoring of nursing homes, CMS nursing home enforcement and enforcement remedies, deficiency severity and scope levels, the origin of fraud, the importance of a compliance and ethics program and its required components, federal compliance-related laws, and guidance on what to do if contacted by government agents or investigators.
- Conduct routine audits to evaluate compliance with Medicaid requirements, including documentation, billing practices, and internal reporting processes. Audits may be performed internally or with the assistance of a third-party reviewer to provide an objective assessment. Findings should be documented, trends analyzed, and corrective actions implemented to address identified risks and support ongoing compliance efforts.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*