Fraud, Waste, & Abuse

What is Fraud, Waste, & Abuse?

Fraud is purposely giving wrong or misleading information in order to get a benefit or some type of service. Waste is over using services or misusing resources or practices. Abuse of the Program is provider practices or member practices that result in an unnecessary cost to the AHCCCS program.

Unfortunately, Fraud, Waste, and Abuse are not as uncommon as you would think. Please see some of the most common examples.

Examples of Member Fraud, and Abuse include but are not limited to:

  • Lending or selling your AHCCCS Identification Card to anyone
  • Not stating true income or living arrangements
  • Providing false materials or documents
  • Leaving out important information
  • Failing to report another insurance that you have
  • Continuing to use AHCCCS for services when you move out of the state or out of the country

Provider Fraud, Waste, and Abuse include, but are not limited to:

  • Billing for a service they didn't provide
  • Ordering test, lab work, or x-rays that aren't needed
  • Charging for medical services not provided
  • Billing multiple payers and receiving double payments
  • Using billing codes that pay higher rates to get more money even though those services weren't provided
  • Billing for services under a member that is not their member

Penalties

A person who is suspected of fraud and/or abuse of the AHCCCS system will be reported to AHCCCS. Penalties for people involved in fraud and/or abuse may be both civil and criminal.

Additional Information

How to Report Fraud and Abuse:

Anyone can report fraud - there are no restrictions. Fraud, Waste, and Abuse hurts everyone. If you suspect a possible case, please report it right away.

If you suspect a BUFC/ALTCS provider or member of fraud, waste or abuse, please contact BUFC/ALTCS at any of the following:

Customer Care Phone: (833) 318-4146

Compliance Officer's Phone: (520) 874-2847

Compliance Department Fax: (520) 874-7072

Compliance Department Email:

BUHPCompliance@bannerhealth.com

Compliance Department Mail:

Banner  - University Family Care/ALTCS

Compliance & Audit Department

2701 E. Elvira Road, Tucson, AZ 85756

Confidential and Anonymous Compliance (ComplyLine) Hotline: (888) 747-7989

Or Report it to AHCCCS, Office of the Inspector General at:

Provider Fraud: (602) 417-4045 or (888) 487-6686

Member Fraud: (602) 417-4193 or (888) 487-6686

www.azahcccs.gov clicking on “Fraud and Abuse”

Mail: Inspector General

701 E. Jefferson Street MD 4500, Phoenix, AZ 85034