Fraud, Waste, & Abuse

What is Fraud, Waste and Abuse?

Fraud is defined by Federal law (42 CFR 455.2) as "an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law."

Waste is defined as overutilization of services, or other practices that directly, or indirectly, result in unnecessary costs to the Medicaid Program. Waste is generally not considered to be caused by criminally negligent actions but rather misuse of resources.

Abuse is defined by Federal law (42 CFR 455.2) as "provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program."

Examples of Member Fraud and Abuse include but are not limited to:

  • Lending or selling your AHCCCS Identification Card to anyone
  • Changing prescriptions written by any UFC provider
  • Giving incorrect information on your AHCCCS application
  • Providing false materials or documents
  • Leaving out important information
  • Failing to tell us about another insurance that you have
  • Continuing to use AHCCCS for services when you move out of the state or out of the country

Examples of Provider Fraud, Waste and Abuse include but are not limited to:

  • Use of the Medicaid system by someone who is inappropriate, unqualified, unlicensed or has lost their license
  • Providing unnecessary medical services leading to unnecessary costs to the program
  • Charging for medical services not rendered
  • Not meeting professional standards for health care
  • Using billing codes that pay higher rates to get more money even though those services weren’t provided
  • Billing for services under a member that is not their member

The above examples are against the law, and as a member, you might lose your AHCCCS eligibility. Legal action may also be taken against you.

WHO CAN REPORT FRAUD, WASTE, OR ABUSE?

Absolutely anyone can report fraud, waste, or abuse. There are no restrictions.

HOW TO REPORT FRAUD AND ABUSE

If you suspect a UFC provider or member of fraud, waste or abuse, please contact us at any of the following:

 

UFC Customer Care Phone: (833) 318-4146

UFC Compliance Officer's Phone: (520) 874-2847

UFC Compliance Department Fax: (520) 874-7072

UFC Compliance Department Email:

UAHPComplianceandAuditMailbox@bannerhealth.com

 

UFC Compliance Department Mail:

University Family Care

Compliance & Audit Department

2701 E. Elvira Rd., Tucson, AZ 85756

Confidential and Anonymous Compliance (ComplyLine) Hotline: (888) 747-7989

Or Report it to AHCCCS, Office of the Inspector General at:

Provider Fraud: (602) 417-4045 or (888) 487-6686

Member Fraud: (602) 417-4193 or (888) 487-6686

 

PENALTIES

A person who is suspected of fraud and/or abuse of the AHCCCS system will be reported to AHCCCS. Penalties for people involved in fraud and/or abuse may be both civil and criminal.