Office of the Inspector General

The Office of Inspector General (OIG) is responsible for the integrity of the AHCCCS budget, nearly $22 billion in State Fiscal Year 2023. It exists to prevent, detect, and recover improper payments due to Medicaid fraud, waste, and abuse.

OIG works closely with federal and state partners, including the Medicaid Fraud Control Unit (MFCU) of the Arizona Attorney General, the Federal Bureau of Investigations (FBI), Drug Enforcement Agency (DEA), Health and Human Services (HHS) OIG, local police and law enforcement agencies, county prosecutors, contracted health plans, and other state agencies.

OIG investigations are often extremely complicated and detailed, requiring significant research, subpoena of third parties, forensic accounting evaluations, medical record reviews, onsite assessment, skip tracing, billing and claims examination, witness interviews, subject matter expert opinion analysis, and evidentiary review in order to determine preliminary findings.

OIG often performs multiple preliminary reviews as each case’s facts and evidence evolve. If, at any point in an investigation, elements of criminal conduct and/or a reliable indication of fraud is determined, OIG partners with the appropriate law enforcement agency. Investigations often take considerable time to obtain these details, sometimes years, depending on the specific case circumstances.

OIG conducts thorough civil and criminal investigations while adhering to its federal, state and contractual requirements. OIG provides appeal rights on its notices that fall under the state statutory definition of appealable agency actions, including but not limited to, provider terminations, credible allegation of fraud payment suspensions, final overpayment findings, and the imposition of civil monetary penalties.

These appeal rights, as set forth in the Arizona Uniform Administrative Hearings Procedures, (A.R.S. § 41-1092 et seq.), include requirements for the types of agency actions that must provide hearing rights, the format of the notice of the agency action, hearing timelines, the provision of informal settlement conferences, and other general agency obligations.