Eligibility Review, Investigation and Recovery (ERIR)

In this section:

• ERIR Unit Responsibilities
• Partnerships With Law Enforcement Agencies
• Impact on AHCCCS
• Reporting Member Eligibility Fraud

ERIR Unit Responsibilities

The ERIR Quality Control Units in the AHCCCS Office of Managed Care is responsible for:

• Conducting field interviews with AHCCCS recipients to determine the accuracy of AHCCCS eligibility decisions made by various entities. The findings of these eligibility reviews are used to establish and report error rates for county eligibility offices, Arizona Long Term Care System (ALTCS) eligibility offices, Premium Sharing, SSI-MAO and KidsCare programs.

• Gather and process data that is used to establish error rates for Department of Economic Security - approved medical eligibility, as well.· 

• The review findings are also used to determine:

1. Error-prone processes and policies.
2. Analyze root causes of the errors.
3. Help the eligibility offices find ways to reduce their rates.

Partnerships With Law Enforcement Agencies

Since implementation in October 1995, the ERIR Member Fraud Investigations Unit has successfully prosecuted cases and currently has cases with successful grand jury indictments pending prosecution. In most cases, members are court-ordered to pay restitution to AHCCCS and serve two years of community service. The Unit has established strong relationships with other agencies in order to be more effective.

• Their relationships with County Attorney offices have made it possible to successfully prosecute member fraud cases.

• Partnerships with other law enforcement agencies, such as the FBI and DEA, allow information to be shared that is important to thorough and complete investigation and successful prosecution.

In July 1998, a second fraud unit, Eligibility Fraud Prevention, was established to investigate applications from hospitalized applicants in the Phoenix Metropolitan area prior to approval for AHCCCS benefits. This unit receives referrals from County Eligibility Interviewers stationed at selected hospital sites and conducts the investigation within 24 hours to determine whether household circumstances are as stated on the application. This provides other wise unavailable information to eligibility interviewers in order to reduce error rates for these costly cases.

Impact on AHCCCS

The error rates established by this Unit determine the dollars which have been spent on recipients who did not meet the eligibility criteria of the program for which they were approved - in other words, misspent taxpayer dollars. When the error rates exceed 3% of federally funded programs such as Long Term Care (LTC), SOBRA and other Medical Assistance Cases (MAO) programs, the State may be subject to dollar sanctions when ineligible recipients are found during a quality control review. When the quality control analysis and fraud investigations are used as a tool to improve the eligibility process, and reduce the error rate, the resulting impact is saved Federal and State taxpayer dollars.

Reporting Member Eligibility Fraud

Member eligibility fraud may be reported to ERIR Member Fraud investigations either by telephone, facsimile, mail or the Internet.

• To report by telephone - the unit's telephone number is (602) 417-4193. You may also call AHCCCS toll free to report suspected member eligibility fraud. The toll free number is 1-888-ITS NOT OK (1-888-487-6686).

• To report by facsimile - the Unit's fax number is (602) 417-4853.

• To report by mail - write to: 

AHCCCS

Member Fraud Investigations

Office of Managed Care, Mail Drop 6100

701 East Jefferson

Phoenix, AZ 85034

• To report by Internet - go to the AHCCCS web site located at www.azahcccs.gov.

1. Scroll down and click on "Fraud and Abuse".
2. Locate and click on "Referral for Preliminary Investigation."
3. Complete the electronic form and submit it to AHCCCS.

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