1801 Fraud and Abuse

Revised 12/17/2024

Policy

The AHCCCS Administration is responsible for ensuring that program resources are not misused or wasted, and that customers receive appropriate care and services. This responsibility is carried out in several ways. 

• Educating the customer or representative of his or her responsibility to report changes and the penalties for perjury and fraud;

• Resolving inconsistent or questionable information received during the eligibility process;

• Identifying, investigating and resolving fraud and abuse cases; and

• Referring concerns to the appropriate area or agency when there is suspected abuse of a customer; and

 

1) Customer Education

Customers and representatives must be given information about their responsibility to report changes that could affect eligibility, premiums or Share of Cost and the penalties for fraud and perjury. This information is provided on application forms and eligibility letters, and is also explained during eligibility interviews. 

For detailed information about reporting changes see Chapter 1500. 

The penalties for fraud and perjury may include civil penalties, repayment of benefits received, and criminal prosecution.

 

2) Resolving Inconsistencies

To prevent fraud and abuse, Benefits and Eligibility Specialists are responsible for resolving inconsistencies when questionable information is received during the eligibility determination process. Information provided by the customer or representative may be questionable when it is inconsistent with:

• Other statements made during the current application;

• Information previously listed on another application; or

• Information received from other sources.

 

The customer’s individual circumstances are considered in determining if information is questionable.

More information or proof may be needed from the customer to resolve the inconsistency. When the customer does not provide the information or proof needed eligibility may be denied or stopped.

 

3) Identifying and Addressing Potential Fraud

Indications of possible fraud include, but are not limited to, the following:

• Altered documents;

• Contradictory statements made by the same individual;

• Conflicting statements about the same issue made by different people;

• Information about the customer’s actual income or resources is not provided or is misrepresented;

• Statements do not agree with information from other proof, documents or applications; and

• Complaints of fraud or abuse received from a third party.

 

Cases with potential fraud indicators are referred to the AHCCCS or DES Office of Inspector General (OIG) for investigation.

See Identifying Potential Fraud for more details about identifying potential fraud.

See Reports of Fraud or Abuse for instructions for taking a fraud report or making a report of fraud or abuse.

Upon receiving a report of potential fraud, the AHCCCS or DES OIG staff review evidence received with the report, investigate, and determine whether the evidence indicates fraud.

When evidence of fraud is found, OIG may refer the case the Attorney General for prosecution.
 

4) Abuse of a Customer

When there is suspected abuse, neglect or quality of care issues, eligibility staff may need to refer the issue to AHCCCS Division of Managed Care Services (DMCS), Adult Protective Services (APS) or the Department of Child Safety (DCS) for follow-up.

A referral to one of these areas may be needed when any of the following are suspected:

• A problem with the quality of care being provided to the customer;

• The customer is being abused, neglected or exploited;

• Provider fraud;

• The customer has unmet healthcare needs;

• A customer living in an unlicensed or uncertified room and board home is receiving direct, personal care services on other than a temporary basis pending ALTCS approval;

• There appears to be a problem with the ALTCS case manager regarding the customer.

 

Definitions

Term	Definition
Abuse of a Customer	Any intentional, knowing or reckless infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, emotional or sexual abuse, or sexual assault.
Exploitation	Illegal or improper use of a vulnerable adult or his resources for another’s profit or advantage
Fraud	Any act of knowing deception or misrepresentation. Fraud includes: Intentionally providing incorrect information or misrepresenting facts with the purpose of obtaining benefits to which the customer would not otherwise be entitled. Lying, misrepresenting, or omitting certain information with the intent to obtain a service, payment, or other gain (e.g. AHCCCS Medical Assistance) to which the individual would not otherwise be entitled. Using another person’s AHCCCS ID card to obtain medical services. Intentionally not reporting changes in income, household composition, living arrangements or other factors that affect AHCCCS eligibility.

 

Legal Authority

Program	Legal Authorities
All programs	42 CFR, Part 455 ARS 36-2905.04