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7.1.1
Introduction
The reporting of potential fraud and 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
AHCCCS and/or ADHS/DBHS programs. Persons receiving care in the
behavioral health system can also commit acts of abuse (e.g., by
loaning or selling their AHCCCS identification card).
Behavioral health
providers must be cognizant of potential fraud and abuse within
the public behavioral health system. Fraud and 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 potential cases of fraud and/or 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 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 information regarding the abuse of a person who
has been determined to be seriously mentally ill (SMI). Section
7.4, Reporting of Incidents, Accidents and Deaths contains information
for reporting abuse of persons determined to have a serious mental
illness.
- T/RBHAs
are responsible for ensuring that mechanisms are in place for
the prevention, detection and reporting of fraud or abuse.
- All
employees of behavioral health providers must be familiar with
the types of fraud and 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 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 abuse involving Title XIX/XXI funds or AHCCCS
registered providers
Upon becoming aware of a suspected incident of fraud or
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.
- AHCCCS Office
of Program Integrity
801 E. Jefferson Street
Phoenix, Arizona 85034
http://www.azahcccs.gov/Site/RptFraud.asp
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
Corporate Compliance Officer
150 N. 18Th Ave., Suite 280
Phoenix, Arizona 85007
(602) 364-3758 or 1-866-563-4927
Fax number: 602-364-4736
7.1.7-B.
Reporting of fraud and abuse involving state-only funds, ADHS/DBHS
registered providers or other providers
Upon becoming aware of a suspected incident of fraud or 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
PM
Form 7.1.1, Suspected Fraud or Abuse Report and faxing
or mailing it to ADHS/DBHS. Reports of fraud or abuse may also be
taken over the phone at (602) 364-3758 or 1-866-563-4927.
7.1.7-C.
Reporting of fraud and 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 abuse. Report suspected Fraud or Abuse to Gila River
Regional Behavioral Health Compliance Officer at (602) 528.7135.
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7.1
Fraud and Abuse Reporting
Last Revised 10/20/2005
Effective Date: 03/15/2006 |
