Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the
Medicaid Cluster
93.778 COVID-19 Medicaid Assistance Program
Agency: Arizona Health Care Cost Containment System (AHCCCS)
Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of B...
Assistance listing number and program name: 93.778 Medicaid Assistance Program (part of the
Medicaid Cluster
93.778 COVID-19 Medicaid Assistance Program
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 May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiates to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for holistic and systemwide changes. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Stop gap strategies implemented include, but may not limited to the following:
· Increased scrutiny of claims based on claims volume.
· Issued a moratorium on new provider registrations for impacted provider types
· Prevented Reimbursement of Claims for Impossibly Rendered Services
· Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment
· Set thresholds for services to initiate a prepayment review.
· Required claims to be billed for specific dates of service rather than ranges.
· Flagged claims for services of the same style/overlapping codes.
· Created a prepayment review process for providers utilizing suspicious billing practices.
· Eliminated retroactive billing.
· Credible Allegation of Fraud (“CAF”) suspensions include both provider entities and owners/ behavioral health (“BH”) practitioners.
· Implemented ID.Me identity verification for AHCCCS Online.
· Required providers to disclose any third-party billing relationships.
· Behavioral Health Providers are now considered high-risk provider types for provider enrollment.
· Per Diem codes have been set to only be able to be billed once per day.
· Practitioners, including Behavioral Health Technicians, can no longer be patients at the same provider.
· Worked with the Arizona Corporation Commission to flag suspicious registrations.
· Ensured AHCCCS coding adhered to National Correct Coding Initiative (“NCCI”) standards and confirmed no edits had been turned off.
· Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards.
Stop gap strategies in process include, but may not be limited to, the following:
· Implementing eligibility integrity requirements for AIHP enrollment.
· Linking BHP to BH companies they work for.
· Link BH Providers to BH facilities they work at.
· Conduct onsite quality of care reviews for patients in treatment longer than 90 days.
· Require medical records to define specialized services.
· Implement a new pre/post pay claims system.
· Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements.
AHCCCS continues to investigate and identify areas of concern and implement necessary system improvements until it is determined that the integrity of the AHCCCS provider network is restored.