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, 2023
Agency’s Response: Concur
In early 2023, AHCCCS completed a staffing analysis which determined additional needed staffing as follows: 1 manager, 3 supervisors, 17 staff investigator positions; permanent funding for 10 time limited investigator positions. In addition, to address workload and costs structurally, AHCCCS is pursuing potential opportunities to partner with contracted Managed Care Organizations (MCO) by referring certain provider and member fraud incidents to MCO contractors for investigation. If such a process is implemented, it is anticipated that referral of investigations to MCO contractors may significantly impact the level of necessary OIG funding and staffing. Such a process may require managed care contract amendments and may also require approval from CMS. As AHCCCS implements the new referral processes, the agency will monitor workload and costs to evaluate whether funding and staffing levels are sufficient and will work with the Legislature to revise appropriations if needed.
AHCCCS implemented a triage process to preliminarily investigate all provider fraud or abuse cases. Cases are preliminarily investigated when they are screened within 90 days of receipt, assigned a priority level, and referred to the Attorney General’s office, or other law enforcement agency, if the cases are identified for criminal investigation.
To screen a case and assign a priority level of a referral of a potential fraud or abuse incident, an OIG supervisor assigns the matter a priority level. Priority One is “MEDIA, DEATH, NEGLECT, IMMEDIATE JEOPARDY/CONCERN, GOVERNOR OR DIRECTOR REFERRAL, CATS (CONSTITUENT AFFAIRS), ASSAULT, PRIORITY LAW ENFORCEMENT, EVIDENCE PRESERVATION”. Priority Two is “ALL OTHER LAW ENFORCEMENT CASES”. Priority Three is “ALL OTHER CASES”. The supervisor enters the priority level for the matter into the OIG SMART database and assigns the matter to an investigator. The SMART database has been programmed to incorporate the prioritization process and OIG staff were trained and the SMART database process was implemented by the end of March 2023.
Upon assignment, investigators review a case for possible referral to the Attorney General’s office, or other law enforcement agency, within 24 hours and thereafter if further investigation warrants. Additionally, to ensure that priority level one cases are preliminarily investigated and referred within 90 days to the Attorney General’s office, or other law enforcement agency, (if applicable), each investigator tracks the progress of the investigation using a spreadsheet which is reviewed with their supervisor on a rotating periodic basis. All 2023 Provider cases have been implemented with these procedures.
The triage and assignment process to preliminarily investigate member fraud or abuse cases was already in existence. Member personnel have a handbook outlining process, procedure, and workflow for their various priorities and allegations. Priority One is “Residency, member death, Joint, Information Only, ALTCS, Voluntary Withdrawal, or Identity Card Issues”. Priority Two is “TPL or Fast Track”. Priority Three is “High Dollar”. Priority Four is “Low Dollar or Short Benefit Time”. Priority Five is “Child Custody or Other Cases”.
Only specific Member Case Priorities and Allegations have preliminary investigation timelines. Priority One cases with an allegation of Residency, ID Card Issues or Member Death are expected to have preliminary investigations completed within 10 days of assignment to an investigator. Priority Two cases with TPL allegations are expected to have preliminary investigations completed within 60 days of assignment to an investigator. Priority Two cases with Fast Track allegations are expected to have preliminary investigations completed within 30 days of assignment to an investigator. All other Priorities and allegation cases have completed investigative timeframes that vary from 120 days to 2 years as defined in the Member Handbook.
AHCCCS has updated its Member handbook to provide clear process expectations, including the standard rotating review of each investigator’s case load with their supervisor to ensure preliminary investigations deadlines are completed, updated entries to the case management system occur, and subsequent allegations are accounted for in the case documentation.