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OIG Recent Cases

Member Fraud 

(Case #1)
Allegations: Subject and her spouse reside in an expensive house, drive a new BMW, own their own business, and are receiving AHCCCS medical benefits.
Findings - Reported monthly income = $1,280 to $1,800
- Unreported monthly income = $7,000
- In the process of purchasing two homes
- In the process of purchasing a BMW with monthly payments of $800+
- Co-owner of a barber shop
- Entire household found ineligible for AHCCCS medical benefits
Resolution: Case referred for prosecution. Subjects pled guilty to Solicitation to Commit Forgery, a class 6 undesignated felony, and were placed on supervised probation and ordered to pay full restitution of $21,101.00


(Case #2)
Allegations: Unreported income and household composition
Findings Subject's spouse was residing in the household and employed with a local school district (unreported wages)
Resolution: Subject pled guilty to Attempted Fraudulent Schemes and Practices, and was sentenced to two years probation, 100 hours community service and to pay restitution in the amount of $13,128.33.


(Case #3)
Allegations: Unreported income - Subject is the Owner/Director of a school and deducts personal expenses as business expenses. It is also reported that the subject recently purchased 900 acres of land in Kansas, paying $147,000 in cash.
Findings Significant income from business, and the household was found to be ineligible for AHCCCS medical benefits.
Resolution: Subject pled guilty to two counts of Tampering with a Public Record, and was sentenced to three years probation, and to pay restitution in the amount of $53,476.70.


(Case #4)
Allegations: Subject and her spouse are residing in California (not AZ residents), while receiving AHCCCS medical benefits. Subjects are using their parent's address for AHCCCS medical benefits. Subjects are also operating a daycare business out of their home, paid $75 to $100 per week per child (5 to 6 children).
Findings Subjects have resided in California for 3 years, and due to Arizona State residency requirements, are not eligible to receive AHCCCS medical benefits.
Resolution: Subjects pled guilty to Theft and sentenced to one day incarceration, three years probation, and ordered to pay restitution in the amount of
$49,059.48.

Provider Fraud 

(Case #1)
Findings Subject entered into a relationship with a doctor and billed AHCCCS for services under that doctor's name. Subject impersonated this doctor and saw/treated patients while the actual doctor was out of the office. Subject billed AHCCCS for services that were not provided by a licensed physician, and for services that were not rendered.
Resolution: Subject pled guilty to a Class 2 Felony, Count 5 Theft, and a Class 3 Felony, Count 6 Money Laundering in the second degree. Subject sentenced to 6 months jail time, and paid restitution in the amount of $144,138.01.


(Case #2)
Findings Doctor had office hours one day per week in Gold Valley, AZ, where he saw patients and wrote in excess of 100 prescriptions in a single day. It was determined that the doctor wrote prescriptions for AHCCCS patients and undercover investigators without obtaining a complete medical history, and did not conduct an appropriate medical examination to obtain diagnostic studies to substantiate the allegation of chronic pain.
Resolution: Doctor/Subject accepted a plea agreement for a Class 2 Felony/Count 4 Fraudulent Schemes and Artifices, a Class 3 Felony/Count 8 Illegal Control of An Enterprise, and a Class 3 Felony/Class 40 Money Laundering. Doctor/Subject forfeited $1,700,000 to AHCCCS.