Sober Living Fraud Response

Overview

Summary

A “Credible Allegation of Fraud” (CAF) payment suspension means that both AHCCCS and law enforcement have reviewed a provider’s billing records and have determined that, based on the evidence available, it is likely that the provider has engaged in intentionally deceptive practices for their own gain.

AHCCCS is required to stop paying a provider and to refer the case to law enforcement for a full investigation as soon as a CAF suspension is issued. Payment suspensions are temporary actions intended to protect public funds while a full investigation is ongoing.

The Current Providers Suspension List does not contain every provider who has been suspended. It only contains providers who are currently suspended. Providers are removed from the list when their suspensions are resolved.

A CAF Suspension may be “rescinded” if:

  • Legal proceedings / investigations related to the alleged fraud do not support a finding of fraud, or
  • Additional information or evidence presented to AHCCCS shows that the provider is not at fault for the alleged fraud.

Review the Rescinding a Credible Allegation of Fraud one-pager for an overview of this process.

Current status Number of Providers (since May 2023)
CAF payment suspension (open law enforcement cases) 277
Quality management terminations 79
Provider moratorium application denials 241
Rescinded CAF suspensions 34
Suspensions upheld at state fair hearing (i.e., a judge heard the case and agreed that the provider engaged in fraud) 28

As of March 26, 2024, the Current Providers Suspension List does not contain every provider who has been suspended, since it only contains providers who are currently suspended. Any provider who has resolved their suspension is removed from the list at the time of that resolution.

Payment suspensions are temporary actions intended to protect public funds while a full investigation is ongoing. Accordingly, payment suspensions must end and are “rescinded” when either legal proceedings related to the alleged fraud are completed or AHCCCS determines there is insufficient evidence of fraud.

Review the Rescinding a Credible Allegation of Fraud one-pager for an overview of this process.

Humanitarian Response

Knowing fraudulent providers may not uphold their member continuity of care obligations, the State stood up a member/victims response effort including the creation of a hotline to assist victims affected by fraudulent providers.

Services include referral assistance, crisis response and assessment, temporary lodging, basic hygiene supplies, food (breakfast, lunch, dinner, snacks), and transportation to hotel lodging, medical appointments, school, and home, including out-of-state airfare and bus transport if required.

Total members assisted in Humanitarian Response over the past year (as of 07/09/2024):

Response/Resource Total Members
Phone calls to 211*7 hotline for resources 33,127
Total Members Served 10,893
Hotel - Temporary Lodging 3,953
Out-of-state Transports 119

Year in Review

In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiates to combat fraud, waste, and abuse in our Medicaid program.

Review the AHCCCS Response to Provider Fraud: Year in Review document for more detailed information about AHCCCS’ response to this sober living fraud scheme between May 16, 2023 and May 16, 2024.

On the Horizon

  • Work with Tribes to identify ways to verify tribal affiliation as a condition of enrollment within AIHP
  • Launch AHCCCS Provider Connect.
  • Linking Behavioral Health Professional (BHP) to BH companies they work for.
  • Link BHPs to BH facilities they work at.
  • Require medical records to define specialized services.
  • Delineate in policy additional requirements of Integrated Clinics and Outpatient Providers (IC/77s).
  • Monitoring how many entities a BHP oversees.
  • Monitor the number of Behavioral Health Technicians (BHTs) supervised per BHP.
  • Implement a new pre/post payment system similar to a clearing house.
  • Requiring direct deposit for AHCCCS reimbursements - Requirement announced and phased rollout is in progress.

Fact Sheets, Information Sheets, and Tools

See the Fact Sheet: AHCCCS Provider Payment Suspension for details of the provider payment suspensions announced in 2023.

See the Medicaid Fraud Allegations Process flier to learn more about steps involved in a Credible Allegation of Fraud payment suspension.

Medicaid Fraud Allegations Process

When a provider is suspended from Medicaid payment or terminated as a Medicaid provider (among other actions), they have due process rights to appeal the action. Learn more about the provider appeals due process in the Provider Termination Due Process Procedures flier.

Provider Termination Due Process Procedures flier

The 4 Steps to Review Provider Credibility flier provides tools to check on provider registration and licensure. First check the AHCCCS Provider Listing tool for registered Medicaid providers. Then check the AHCCCS Provider Suspension list. If the provider is registered and not suspended, check for a license, deficiencies, and corrective actions at www.azcarecheck.com. You can also search for a provider’s professional license with the appropriate organization: Arizona Board of Nursing, Arizona Board of Behavioral Health Examiners, Arizona Medical Board (for doctors and physician assistants), or Arizona Board of Psychologist Examiners.

4 Steps to Review Provider Credibility

The Rescinding a Credible Allegation of Fraud one-pager is an overview of the process and the ways in which providers can have their payment suspension lifted.

rescinding fraud

External Audit Results

Status of Recommendations
Implemented Implementing
Member Recommendations: 2, 3, 4, and 5 Member Recommendation: 1
Post-Payment Recommendations: 2, 3 ,4, 5, 6, 7, 8, 10, 11, 12*, 13, 15*, 16*, 17*, 18, 20 Post-Payment Recommendations: 1, 9, 14, 19
Broad Initiative Recommendations: 1* Broad Initiative Recommendations: 2*, 3*
*Recommendations were implemented (or are being implemented) through strategies other than the specific method identified in the report.

For more information, review the official audit report.

Background

In April 2023, AHCCCS contracted with an external auditor, Berry Dunn, to analyze AHCCCS data, identify trends, and make recommendations on how the agency can prevent fraud, waste, and abuse moving forward. This comprehensive audit reviewed both the agency’s claims and enrollment processes to ensure bad actors were prevented from entering the system or billing fraudulently.

Results

As a result of the forensic audit, Berry Dunn made 25 programmatic recommendations to the agency, as well as three recommendations for broad initiatives. Of the 25 programmatic recommendations, AHCCCS has implemented 20, and is in the process of implementing another five (as of May 2024). AHCCCS is also implementing the three recommendations for broad initiatives through internal operational and staffing enhancements. Overall, the findings reinforced and provided external validation for the approach AHCCCS has taken to combat fraud and protect members from bad actors.

Newsroom

AHCCCS appreciates the role of journalists in upholding the public’s interest and right to be informed of the government's use of taxpayer dollars. We strive to be transparent, responsive, and informative, and to ensure that facts are delivered accurately and in a timely fashion.

Media Highlights

Legal Actions:

Bad Actor Scheme:

Response Coverage:

Tribal Outreach Efforts

Know the red flags. Protect yourself and your family from dishonest health providers. Learn the warning signs to stay safe.

In May 2024, AHCCCS launched a public awareness campaign that includes digital toolkits for Tribal members and leaders, and for frontline workers, that includes social media posts, influencer scripts, fliers, infographics, web banners, and wallet card.

Toolkits:
Tribal Outreach Toolkit
Frontline Worker Toolkit

In addition, AHCCCS launched a new Tribal Resources web page to help educate members, providers, and others about the red flags when it comes to fraudulent providers, and to provide valuable resources to empower Tribal members. Visit www.azahcccs.gov/TribalResources for more information.

Provider Outreach Efforts

Image of Ava, the new chatbot on the AHCCCS website

As of April 2024, AVA (AHCCCS Virtual Assistant), the chatbot on the AHCCCS website and AHCCCS Online portal, has expanded capabilities to answer common provider questions on enrollment, Fee-for-Service (FFS) claims, and FFS prior authorization, as well as transfer to a live agent during business hours (Monday - Friday, 8 a.m. - 4:30 p.m., excluding state holidays).

In July, AHCCCS will launch AHCCCS Provider Connect, the ability to text and email providers or the credentialing representative at important enrollment points, including revalidation and license expiration.



Covered Behavioral Health Services Guide

AHCCCS has published the Covered Behavioral Health Services Guide (CBHSG) with an effective date of 10/1/2024.

While the guide is not subject to public comment, AHCCCS will be collecting questions on the guide between 7/15/2024 and 9/15/2024 in order to facilitate the development of a frequently asked questions (FAQs) and training materials for providers and stakeholders that will be posted on the AHCCCS website.

Please submit all questions via email to CBHSGCodingQuestions@azahcccs.gov. Questions will only be gathered via this email box.

The guide has been published to the Medical Coding Resources web page and can be found under the Behavioral Health Service Matrix and Guide drop down menu.

Quality of Care Concerns

AHCCCS is committed to ensuring that all members receive quality health care and are able to access services. If you or any AHCCCS member has experienced a barrier to getting health care services or have concerns about the quality of services received, please report it to Clinical Quality Management (CQM) by completing this form, calling (602) 417-4885, or by emailing CQM@azahcccs.gov.

Report Fraud, Waste, and Abuse

There is no wrong way to report fraud!

The Office of Inspector General (OIG) investigates reports of suspected fraud, waste, and abuse of AHCCCS programs. Each year, OIG recovers and saves tens of millions of dollars in fraudulent claims against Medicaid.

The primary way AHCCCS discovers fraud is through reports from people like you who report it to us.

What does fraud look like?

Fraud is when someone lies or gives false information with the intent to receive benefits or payments for which they are not legally eligible. Fraud can be committed in a variety of ways. Here are just a few:

Members:

  • Providing Incorrect Household Composition Information
  • Falsifying Income and Not Reporting Income
  • Hiding Employment or Self-Employment Information
  • Falsifying Arizona or US Residency Status
  • Unreported other insurance
  • Misrepresenting medical condition/s or ethnicities

Providers:

  • Performing and/or billing medically unnecessary services
  • Making False Statements and False Claims
  • Billing for Services and Supplies Not Provided
  • Double Billing, Over Billing, and Incorrect Coding
  • Committing Prescription and Pharmacy Fraud
  • Paying for and/or receiving kickbacks

Report Fraud or Abuse

Report Member, Provider, or Contractor Suspected Fraud or Abuse of the Program via an online form or follow the steps outlined below for provider and member fraud reporting.

Report Provider Fraud

If you want to report suspected fraud by medical provider, please call the number below:

  • In Arizona: 602-417-4045
  • Toll Free Outside of Arizona Only: 888-ITS-NOT-OK or 888-487-6686

Report Member Fraud

If you want to report suspected fraud by an AHCCCS member, please call the number below:

  • In Arizona: 602-417-4193
  • Toll Free Outside of Arizona Only: 888-ITS-NOT-OK or 888-487-6686

Questions

Contact the AHCCCS Office of Inspector General with questions about fraud, waste or abuse of the program, or abuse of a member at AHCCCSFraud@azahcccs.gov.

Resources