Office of the Inspector General
The Office of Inspector General (OIG) is responsible for the integrity of the AHCCCS budget, nearly $18 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.
OIG at a Glance
Provider Compliance Division
- → Using data mining, the three units in this division conduct provider investigations of external referrals and internally detected cases, and make independent referrals to the State Medicaid Fraud Control Unit (MFCU) and other city, state, and federal law enforcement agencies.
- → Within this division, the Member Criminal Investigations Unit and the Fraud Prevention Unit play distinctive roles, each conducting reviews of post- and pre-enrollment to identify potential fraud involving members.
- → This team oversees the Corporate Compliance Program as required by federal law and AHCCCS managed care contracts. The four units in this group conduct performance improvement projects and independent provider audits.
- → This team’s function is data mining and using data to drive case work. They conduct ad-hoc data sampling, post payment data audits, and periodic utilization reviews of target providers to identify trends and determine potential fraudulent billing practices.
- → This specialized team conducts complex financial and corporate health care fraud investigations and provides financial fraud analysis investigation assistance and training.
Facts About Behavioral Health Billing Fraud
See the Fact Sheet: AHCCCS Provider Payment Suspension for details of the provider payment suspensions announced in 2023.
See the Medicaid Fraud Allegations Process flier to learn more about steps involved in a Credible Allegation of Fraud payment suspension.
When a provider is suspended from Medicaid payment or terminated as a Medicaid provider (among other actions), they have due process rights to appeal the action. Learn more about the provider appeals due process in the Provider Termination Due Process Procedures flier.
The 4 Steps to Review Provider Credibility flier provides tools to check on provider registration and licensure. First check the AHCCCS Provider Listing tool for registered Medicaid providers. Then check the AHCCCS Provider Suspension list. If the provider is registered and not suspended, check for a license, deficiencies, and corrective actions at www.azcarecheck.com. You can also search for a provider’s professional license with the appropriate organization: Arizona Board of Nursing, Arizona Board of Behavioral Health Examiners, Arizona Medical Board (for doctors and physician assistants), or Arizona Board of Psychologist Examiners.
Contact AHCCCS OIG
General Questions and Fraud Reporting
OIG Administrative Assistant, (602) 417-4193
General AHCCCS Information
Contact: (602) 417-4000