A. Chapter Contents

This chapter contains the following topics:

Topic

1801.00    Identifying Possible Fraud

1802.00    Eligibility Specialist Responsibilities

1803.00    Complaints of Fraud

1804.00    Fraud Referrals

1805.00    Office of Investigations

1806.00    Non-Payment of ALTCS Share of Cost

B. Introduction

In this chapter you will learn:

• How to identify fraud;

• How the Eligibility Specialist can help prevent fraud and abuse;

• How to handle complaints alleging fraud or abuse;

• What to do if you suspect a customer is the victim of abuse or neglect;

• How to make a referral to the AHCCCS Member Fraud Investigations Unit;

• How the Member Fraud Investigations Unit processes referrals;

C. Definitions

The following terms apply to this chapter:

Term

Definition

Abuse

Abuse means customer practices that result in unnecessary cost to the Arizona Health Care Cost Containment System. 

Abuse includes:

• Purposely overusing the system for the customer's benefit (e.g., consistently demanding unnecessary medical care).

• Non-payment of a customer's share of cost by a representative who is receiving the customer's income (MS 1804).

• Transferring a customer's assets without giving the customer something of equal value

Abuse of a Customer

Abuse of a customer means 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 (ARS 46-451 & 13-3623).

Fraud

Fraud is an 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 Health Insurance) to which the individual would not other wise is 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

D. Legal Authorities

42 CFR, Part 455

ARS 36-2905.04

A. Introduction

All questionable information provided by the customer or the customer's representative must be verified if it could affect the customer's eligibility.

B. Questionable Information

Information provided by the customer or representative is questionable if it is inconsistent with other statements made during the current application or previous applications, or with information received from other sources. Consider the customer's individual circumstances in determining if information is questionable.

C. Expenses That Exceed Income

Although comprehensive information on expenses is not required for eligibility determinations, information may be available which indicates that the customer's expenses exceed income (EEI). If it appears that an EEI situation exists, follow the policy and procedures in MS 608.

D. Indications of Possible Fraud

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

• Alterations in documents;

• Contradictory statements made by the same individual;

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

• Statements that don't agree with information shown on other documents; and

• Complaints of fraud received from a third party or an anonymous report.

A. Introduction

The Eligibility Specialist is responsible for:

• Resolving inconsistencies when questionable information is received during the application process;

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

• Making referrals to the Office of Program Integrity when there is a suspicion of fraud or abuse or someone alleges that a customer who is receiving AHCCCS Health Insurance is involved in fraud or abuse;

• Making a Customer Issue Referral when there is suspicion of abuse of a customers; and

• Making referrals to Adult and Child Protective Services when appropriate (MS 1802.F.).

B. Applications

When questionable or suspicious information is provided during the application process, investigate and resolve the apparent inconsistencies as part of the eligibility determination process. 

If the customer does not provide information to resolve the inconsistencies, deny the application. 

Do not make a referral to the Office of Program Integrity if the customer has not received AHCCCS Health Insurance.

C. Reporting Changes and Penalties

Ensure that the customer and/or representative receive information about reporting changes that could affect the customer's eligibility and the penalties for fraud. 

• Provide this information on application forms and eligibility notices. 

• Explain reporting requirements and penalties for fraud during face-to face interviews.

D. Complaints of Fraud or Abuse

Follow the instructions in MS 1803 when you receive a complaint of fraud or abuse.

E. Identifying Possible Fraud

Suspect possible fraud when the following key factors exist:

• The customer or representative presents a fraudulent (misleading) representation as a statement of fact;

• The customer or representative knows or believes that the misleading representation or omission of facts is untrue or makes the misrepresentation or omission with reckless disregard of the truth;

• The misrepresentation is made for the purpose of influencing eligibility-related decisions, provision of benefits, or claims processing payment decisions.

• The fact misrepresented is significant in determining the customer's eligibility. An incorrect age, for example, is not material except when age is an eligibility factor. Willful failure to report facts which would result in ineligibility includes, but is not limited to, the following:

o    Property ownership, real or personal, which is in excess of the ALTCS resource limit;

o    Understated or omitted income which, if considered, makes the customer ineligible for the AHCCCS Service Package he or she is receiving, or raises the amount the customer must pay toward medical expenses (premiums or ALTCS share of cost).

Follow the instructions in MS 1804 to make a referral for fraud investigation.

F. Abuse of a Customer

Use the Customer Issue Referral (DE-638) to Inform the Division of Health Care Management of abuse, neglect or quality of care issues. 

Complete a DE-638 if you suspect any of the following:

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

• The customer is being abused or neglected;

• Provider fraud;

• The customer has unmet medical or dental needs;

• A customer who is residing in an unlicensed or uncertified room and board home is receiving direct, personal or supervisory 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.

G. Referrals to Adult or Child Protective Services

Report physical or financial mistreatment of an incapacitated or vulnerable adult to the Arizona Department of Economic Security's Adult Protective Services (APS). 

Report suspected physical or sexual abuse or neglect of any child to the Arizona Department of Economic Security's Child Protective Services (CPS). 

When a referral to CPS or APS may be appropriate, discuss the issue with your supervisor. In some cases, depending on the severity of the issue, the discussion may occur after the referral has been made. 

Complete the Customer Issue Referral, fully documenting the problem and all actions taken to resolve the problem. The supervisor needs to review the referral before it is forwarded to Division of Health Care Management (DHCM).

A. Referring Calls to the Member Fraud Investigation Unit

Refer individuals calling to report alleged fraud by a customer who is receiving AHCCCS Health Insurance to the AHCCCS Fraud Hotline at: (602) 417-4193 or (888) 487-6686 (for callers who are outside the Phoenix area).  

Transfer the call or ask the complainant to call directly. This phone is answered during normal working hours, Monday through Friday. Voice Mail is available on this phone after hours to record messages.

B. Accepting Reports of Fraud

When a complainant insists on giving details of the alleged fraud or abuse to you in person or by phone, rather than calling the AHCCCS Fraud Hotline, take the following action:

 Step

Action

1

Tell the complainant that if they choose to identify themselves, their identity is kept confidential but may be released to the prosecutor in the event the case is prosecuted. We cannot promise complete confidentiality. 

NOTE: Due to Privacy Act restrictions, individuals reporting acts of fraud or abuse cannot be advised of the investigative results.

2

Obtain as much information as possible to identify the customer (Name, date of birth, Social Security Number, address, etc.). 

3

Ask the complainant specific details on how the complainant believes the customer or representative is defrauding or abusing the AHCCCS program.

4

Call the AHCCCS Fraud Hotline on the complainant's behalf.

A. Overview

Eligibility Specialists are not responsible for investigating fraud and abuse, but they are required to gather sufficient information to make a referral to the Office of Program Integrity when fraud or abuse is suspected or reported.

B. Referral Procedure

Complete the following steps if you suspect fraud or receive a report of fraud:

 Step

Action

1

Document the case record in sufficient detail to permit a reviewer to determine the accuracy of your determination the reason that information provided by the customer or representative is considered questionable. 

2

Have your immediate supervisor review the case record documentation and all pertinent information and documents that relate to the suspected fraud. 

The Administration encourages all employees to immediately report any type of suspected fraud or abuse with the AHCCCS system.

3

With approval from your immediate supervisor, make a referral to the Office of Program Integrity:

• Call the Fraud Hotline at (602) 417-4193' or

• Submit an electronic referral by completing the information requested at www.azahcccs.gov/fraudabuse/.

A. Introduction

The Office of Investigations, located in the Office of Program Integrity is responsible acting upon requests for investigation submitted by the general public, health plans, providers, AHCCCS customers or AHCCCS employees, when fraud or abuse on the part of an AHCCCS customer (recipient) is alleged. 

NOTE: The Office of Program Integrity also investigates allegations of provider fraud and abuse and conducts internal investigations.

B. Overview of the Investigation Process

The AHCCCS Office of Investigations initiates the following actions after receiving a report of alleged fraud or abuse:

Step

Action

1

Review any supporting evidence gathered to see if it substantiates an allegation of fraud or abuse.

2

Determine if they are going to take action.

If. . .

Then. . .

No action will be taken

They notify the referring AHCCCS office of this decision.

They decide to take action

They contact the customer or representative to inform them of the allegations.

3

Conduct the investigation.

4

When evidence of fraud is found, the Member Fraud Investigations Unit may implement one or more of the following procedures:

• Contact the customer or representative requesting recovery of monies expended for services that were fraudulently obtained; or

• Refer the case to the Attorney General's office or designated law enforcement agency (e.g., County Attorney's Office) for prosecution.

NOTE: The Director, Office of Program Integrity determines whether the customer or representative may see any portion of a request for investigation, report of the investigation, or any portion of a case record involved in a fraud investigation.

A. Effect on Eligibility

Failure to pay the ALTCS share of cost (SOC) does not result in ineligibility for an ALTCS customer.

B. Nursing Facility Option

The nursing facility can ask the program contractor to make a referral to the Financial Field Operations Unit in AHCCCS Central Office when:

• The SOC involves Social Security funds; and

• The customer's legal representative or any other representative is responsible for paying the customer's assessed share of cost but does not. 

If the customer has a legal representative, the program contractor should also make a referral to the legal authority (i.e., Probate Court), which appointed the representative.

C. Referral Criteria

Before making a referral, the following criteria must be met:

• The customer must be receiving Social Security payments that are expected to be used (at least in part) to pay the SOC;

• A Legal representative, authorized representative or someone other than the customer must be receiving the customer's income and that person must be responsible for handling the customer's finances and paying the share of cost (SOC).

• The SOC must be delinquent and the delinquency must exceed $5,000.

• The program contractor must be able to demonstrate that at least two letters have been sent to the representative demanding payment of the delinquency.

D. Referral Process

AHCCCS local offices are not involved in this referral process. However if you erroneously receive a referral packet, immediately forward the packet to the Financial Operations Unit in the Central Office. The program contractor is responsible for informing sub-contracting nursing facilities of the proper procedure and required documentation for making referrals.

 Step

Action

1

The nursing facility prepares the referral packet and forwards it to the program contractor. The referral packet must contain the following:

• The customer's name, address, ACE ID number or AHCCCS ID number;

• The name, address and phone number of the nursing facility or program contractor and the name of a contact person;

• The name, address and phone number of the customer's representative;

• A memo or other written narrative describing the situation, contacts that have already been made with the representative, and details of the delinquency (how much SOC is unpaid and for what months); and

• Copies of at least two letters written to the representative demanding payment of the delinquency.

2

The program contractor:

• Reviews the packet for completeness;

• Sends the completed packet to:

Division of Member Services

Financial Field Operations Unit, Mail Drop 2600

801 E. Jefferson, Phoenix, AZ 85034-2246;

• Tracks the referral; and

• When a legal representative does not pay the SOC, the program contractor also makes a referral to the entity (Probate Court, etc.), which bestowed that authority upon the representative.

3

The Financial Field Operations Unit:

• Reviews the referral packet for completeness;

• Verifies that Social Security payments are involved in the SOC payment;

• May contact the nursing facility or program contractor for additional information;

• Recalculates the customer's SOC for the delinquent time period to ensure that the SOC was correct; and

• Has the Technical Service Center correct the share of cost if it was incorrect.

If . . .

Then the Financial Field Operation Unit. . .

The referral does not meet the referral criteria due to the recalculation of the SOC

Returns the referral packet to the program contractor.

The SOC amount is validated and the referral packet is complete

Forwards the referral packet to the Office of Program Integrity.

4

The Office of Program Integrity may refer the packet to the Social Security Office of Inspector General if the SOC involves Social Security funds. 

If the SOC involves any other funds, the Office of Program integrity does not have jurisdiction to conduct an investigation. The incident becomes a private matter between the Nursing Facility and the Authorized Representative.