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7.1.1
Introduction
The reporting of suspected fraud and program abuse is intended to avoid
the misappropriation of Federal, State and Local funds. In the context
of this section of the provider manual, "fraud" is considered an act
of purposeful deception committed by a person or behavioral health
provider to gain an unauthorized benefit. "Abuse" committed by a behavioral
health provider (for purposes of this section of the provider manual)
means activities that are inconsistent with standard fiscal business
or medical practices and that result in unnecessary costs to the
Arizona Health Care Cost Containment System (AHCCCS) and/or the
Arizona Department of Health Services/Division of Behavioral Health
Services (ADHS/DBHS) programs. Persons receiving care in the
behavioral health system can also commit acts of program abuse (e.g., by
loaning or selling their AHCCCS identification card).
Behavioral health
providers must be cognizant of the potential for fraud and program abuse within
the public behavioral 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 behavioral health services and
can result in monetary fines, criminal prosecution, the termination
of providers and prohibition from participation in Medicare/Medicaid
Programs. This section outlines the procedures for behavioral health
providers to report suspected incidents of fraud and/or program abuse.
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7.1.2
References
The following citations can serve as additional resources for this
content area:
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7.1.3
Scope
To whom does this apply?
- All
Tribal/Regional Behavioral Health Authority (T/RBHA)
enrolled persons receiving behavioral health services; and
- All behavioral
health providers.
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7.1.4
Did you know…?
- This section
does not include reporting of physical and sexual abuse
regarding persons who have been diagnosed with 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.
- T/RBHAs
are responsible for ensuring that mechanisms are in place for
the prevention, detection and reporting of fraud or program abuse.
- All
employees of behavioral health providers must be familiar with
the types of fraud and program abuse that could occur during their normal
daily activities.
- ADHS/DBHS
and each T/RBHA have designated a compliance officer and compliance
committee designed to prevent and detect suspected fraud or
program abuse.
- Any person
who knowingly obtains any benefit by means of false or fraudulent
pretenses, representations, promises or material omissions is
guilty of a Class 2 Felony.
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7.1.5
Definitions
Abuse
Fraud
7.1.6
Objectives
To identify requirements for behavioral health providers
to report suspected cases of fraud or abuse.
7.1.7
Procedures
7.1.7-A.
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 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 Office
of Program Integrity of the suspected fraud or abuse in writing
to the address below or by submitting an online form accessible
at the link below.
In addition,
T/RBHAs or providers should advise the ADHS/DBHS Corporate Compliance
Officer of the report to AHCCCS by calling or writing to the contact
information below.
- ADHS/DBHS
Office of Program Integrity
1740 West Adams, #409
Phoenix, Arizona 85007
(602) 364-3758 or 1-866-569-4927
Fax number: (602) 542-3940
Email:
reportfraud@asdhs.gov
7.1.7-B.
Reporting of fraud and program abuse involving Non-Title XIX/XXI
funds or ADHS/DBHS
registered providers or other providers and recipients
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 10 working days to inform the ADHS/DBHS Corporate Compliance
Officer by completing the
Suspected Fraud or
Program Abuse Report and faxing, mailing or emailing it to
the 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.
7.1.7-C.
Reporting of fraud and program abuse to the T/RBHA
In addition to notifying ADHS or AHCCCS, behavioral 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.
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7.1
Fraud and Program Abuse Reporting
Last Revised 12/01/2010
Effective Date: 12/01/2010 |
