Assistance listing number and program name: 93.778 Medical Assistance Program (Medicaid Title XIX)
Agency: Arizona Health Care Cost Containment System (AHCCCS)
Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance
Anticipated completion date: Decembe...
Assistance listing number and program name: 93.778 Medical Assistance Program (Medicaid Title XIX)
Agency: Arizona Health Care Cost Containment System (AHCCCS)
Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Budget and Finance
Anticipated completion date: December 31, 2024
Agency’s Response: Concur
In response to this item, AHCCCS has made holistic, system-wide improvements to the Medicaid payment system, including:
1. Required behavioral health providers to submit additional assessment, treatment plan, and medical records documentation with their claims,
2. Required Fee-For-Service providers billing more than 2 units of hourly codes or 4 units of 15-minutes codes on a single date of service, to provide additional documentation,
3. Added new reporting to flag concerning claims for review before payment, including, but not limited to, claims for services that could not be rendered as billed, claims for substance use treatment for minors age 12 and under, claims for services by different providers that should not be provided on the same day, and overlapping services of the same style,
4. Set billing thresholds and imposed prepayment review for various scenarios including multiple providers billing the same client on the same day for similar services, excessive number of hours per day, and the age of patients,
5. All codes intended for per diem services have been limited in the system and providers must bill each day separately rather than in date ranges, so per diem codes cannot be billed more than once a day on any given date of service,
6. Researched and confirmed that the National Correct Coding Initiative (NCCI) Medicaid coding methodologies, which allow for states to reduce improper payments, are in place and functioning correctly,
7. Set a specific rate for billing code H0015 for drug and alcohol treatment services, a change from the previous rate that paid a percentage of the billed amount,
8. Hired a forensic auditor to review all claims since 2019,
9. Implemented emergency rules to enhance and expand AHCCCS authority to exclude providers affiliated with bad actors,
10. Elevated three behavioral health provider types to the high-risk category for all new registrants, requiring fingerprints, on-site visits, background checks, and additional disclosures,
11. Implemented federal authority to impose a moratorium on new provider registrations for all Behavioral Health Outpatient Clinics, Integrated Clinics, Non-Emergency Transportation providers, Behavioral Health Residential Facilities, and Community Service Agencies,
12. Ended approval of retroactive provider registrations without good cause documentation,
13. Eliminated the ability for providers to bill on behalf of others,
14. Eliminated the ability for a member to switch enrollment from a managed care health plan to the American Indian Health Program (AIHP) over the phone,
15. Added a data request process for law enforcement agencies to assist with missing persons cases, and
16. Revised the Provider Participation Agreement (PPA) to explicitly require that if a provider stops providing services to AHCCCS members during an ongoing investigation, they must help the member transition to a new provider for care. Similarly, they are required to provide to AHCCCS a member census and, upon request, any other information needed to assist in care coordination. If they do not comply, AHCCCS has the right to file an injunction to require the provider to comply with the PPA.
AHCCCS plans to implement additional measures to further strengthen the agency’s ability to detect and prevent potentially fraudulent activity. A partial list includes:
• Requiring visual attestation of individual billers,
• Requiring third-party billers to disclose terms of compensation, and
• Determine methodology for AIHP enrollment criteria.