The reporting of suspected fraud and program abuse is a requirement of the Arizona Department of Health Services, Division of Behavioral Health Services (ADHS/DBHS) Corporate Compliance Program. Under those requirements, T/RBHAs and their subcontracted providers are required to immediately notify the Arizona Health Care Cost Containment System (AHCCCS), Office of the Inspector General (OIG) and ADHS/DBHS Bureau of Corporate Compliance (BCC) regarding any suspected fraud or program abuse involving AHCCCS, federal or state funds. ADHS/DBHS/BCC works closely with AHCCCS/OIG to address all the referrals reported by providers in order to improve the system and promote accountability. This section does not include reporting of physical and sexual abuse regarding persons who have been determined to have a Serious Mental Illness (SMI).
Section 7.4, Reporting of Incidents, Accidents and Deaths, contains information for reporting abuse of persons determined to have a SMI.
Providers must be cognizant of the potential for fraud and program abuse within
the public health system. Fraud and program abuse can result
in the misuse of federal and state funds, can jeopardize the care
and treatment of persons receiving covered services and
can result in monetary fines, criminal prosecution, the termination
of providers and prohibition from participation in Medicare/Medicaid/State-funded
Programs. This section outlines the procedures for providers to report suspected incidents of fraud and/or program abuse.
In the context of this section of the Provider Manual, persons receiving care in the health system can also commit acts of program abuse (e.g., by loaning or selling their AHCCCS identification card).
Definitions for terms are located online at
http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:
All T/RBHAs are responsible for ensuring that mechanisms are in place for the prevention, detection and reporting of fraud and/or program abuse. All employees of providers must be familiar with the types of fraud and/or program abuse that could occur during their normal daily activities. ADHS/DBHS and each T/RBHA have designated a Compliance Officer and Compliance Committee responsible for the development and implementation of the Corporate Compliance Program which addresses fraud and program abuse prevention and detection. Any person(s) found to be guilty for knowingly obtaining any benefit by means of false or fraudulent pretenses, representations, promises or material omissions could be charged with a Class 2 Felony.
Reporting of fraud and program abuse involving Title XIX/XXI funds or AHCCCS
registered providers and recipients
Upon becoming aware of a suspected incident of fraud and/or
program abuse, including a suspected incident committed by the T/RBHA, a
T/RBHA or provider has 10 working days to inform the AHCCCS/OIG of the suspected fraud or abuse in writing
to the address below or by submitting an online form accessible
at the link below.
Office of Inspector General
701 E. Jefferson Street, Mail
Phoenix, Arizona 85034
Phone: (602) 417-4193 or (602) 417-4045
Fax: (602) 417-4102
T/RBHAs or providers should advise the ADHS/DBHS Corporate Compliance
Officer of the report to AHCCCS by calling or writing to the contact
Bureau of Corporate Compliance
150 N. 18th Ave, Ste. 250
Phoenix, Arizona 85007
(602) 364-3758 or 1-866-569-4927
Fax number: (602) 542-3940
Reporting of fraud and program abuse involving Non-Title XIX/XXI
funds and/or grants
Upon becoming aware of a suspected incident of fraud or program abuse, including
a suspected incident committed by the T/RBHA, a T/RBHA or provider
has ten (10) working days to inform ADHS/DBHS/BCC by completing the
Program Abuse Report Form and faxing, mailing or
emailing it to ADHS/DBHS at the address listed above. Reports of fraud or
program abuse may also be
taken over the phone at (602) 364-3758 or 1-866-569-4927.
Reporting of fraud and program abuse to the T/RBHA
In addition to notifying ADHS or AHCCCS, health providers
may need to notify their contracted T/RBHA of all suspected incidents
of fraud or program abuse. Report suspected Fraud or program Abuse to Gila River
Regional Behavioral Health Compliance Officer at (520) 550-6207.
The following citations serve as additional resources for this
Fraud and Program Abuse Reporting
Last Revised 7/15/2014
Effective Date: 7/15/2014