AHCCCS Fraud - Federal Charges & Defenses

Since the pandemic began, Arizona authorities have charged dozens of people and businesses with allegations of AHCCCS fraud. The total amount of money involved in these cases is staggering, with fraudulent claims exceeding $100 million. To put it in perspective, the amount billed under the Native American AHCCCS code went from $53 million in 2019 to a sky high amount of $668 million in 2022.

Since the beginning of 2022, the AHCCCS Office of the Inspector General has terminated 87 service providers who were believed to be involved in targeted fraudulent activities.

Additionally, the office has suspended various payments to these providers. To further defend the level of care and services, AHCCCS has also increased resource allocation for monitoring quality and has started performing in-person reviews at facilities to confirm the health and safety of its members.

AHCCCS insurance fraud includes a wide range of fraudulent practices, such as billing for services not rendered, double billing, billing for deceased patients, and other deceptive practices targeting Arizona Medicaid benefits. Here's what it encompasses:

• Billing for Nonexistent Services: Some providers have been accused of billing the state for treatment never provided, such as charging for more hours than they stayed open or for 24-hour services.
• Deceptive Billing Practices: Other practices include double billing and billing for patients who were elsewhere at the time of alleged treatment.
• Targeting Vulnerable Populations: Instances have emerged where providers have specifically targeted Native Americans, preying on their needs for drug and alcohol rehab, only to leave them stranded.

▶ Scope of Healthcare Fraud Charges

The scale of AHCCCS fraud is widespread with allegations involving hundreds of millions of dollars. According to this press release, in May of 2023, Governor Katie Hobbs and Arizona Attorney General Kris Mayes joined the AHCCCS Office of Inspector General (OIG) to suspend payments of more than 100 health providers and behavioral health services that are accused of healthcare insurance fraud and abuse.

The Governor has also ordered third-party audits to determine the extent of the fraud. Meanwhile, efforts are being made to examine fraudulent schemes that take advantage of Native Americans, an issue aggravated by the fact that Native Americans are 500% more likely to experience alcohol-induced deaths and 20% more likely to die from drug use, according to a 2021 report by Arizona’s Department of Health Services.

▶ Impact on Vulnerable Communities

The impact of AHCCCS fraud extends beyond monetary loss to the state. It undermines trust in the healthcare system and disproportionately affects vulnerable communities, particularly Native Americans.

• Human Cost: The fraudulent schemes have led to human suffering, such as a sober living facility leaving individuals stranded far from home or exploiting their healthcare needs.
• Community Disruption: The proliferation of fraudulent group homes has caused unrest in neighborhoods, leading to fear and uncertainty among residents.
• Erosion of Trust: The continued occurrence of fraud has eroded public trust in AHCCCS and healthcare providers, making it more challenging for genuine providers to serve the community.