Understanding Arizona AHCCCS Fraud: ARS 20-463 & ARS 13-2310

Arizona AHCCCS fraud involves dishonest actions to get unwarranted money or services from Arizona’s Medicaid program. Below are some of the most common examples of AHCCCS fraud:

Billing for Services Not Provided 

Billing for services not provided occurs when a provider submits claims to AHCCCS for medical services, procedures, tests, or treatments that were never delivered. This may include inflating the number of visits a patient received or creating claims for services that were never performed. For example, a provider might claim a patient had five visits when they only had two or submit bills for tests that were never performed.

Falsifying Patient Diagnoses

Falsifying patient diagnoses occurs when a healthcare provider intentionally misrepresents a patient’s condition to obtain payment for services that are not medically necessary. This fraudulent practice may include exaggerating the severity of an illness, inventing conditions, or otherwise altering medical records to justify billing AHCCCS for unwarranted procedures or treatments. For example, a provider might claim a patient has a serious illness when the patient only has a minor condition, allowing the provider to bill AHCCCS for expensive, unnecessary services.

Misrepresenting Procedures Performed

Misrepresenting procedures performed occurs when a provider intentionally submits claims to AHCCCS that do not accurately reflect the services delivered. This may involve billing for procedures that were never performed, altering procedure codes to obtain higher reimbursement, or misclassifying services to secure payment for noncovered care. 

Upcoding and Unbundling

Upcoding and unbundling are two common forms of AHCCCS fraud. Upcoding occurs when a provider bills for a more expensive procedure than the one actually performed. For example, charging for a complex surgery when only a simple procedure was performed. Unbundling occurs when a provider bills separately for services that should be grouped together and billed as a single procedure. Both practices inflate costs and improperly shift expenses onto the AHCCCS program.

Eligibility Fraud

Eligibility fraud occurs when an applicant or member knowingly provides false or misleading information to obtain AHCCCS benefits for which they are not eligible. Examples include underreporting income, misrepresenting residency, or concealing assets. Such conduct undermines the program’s purpose by diverting limited resources away from eligible individuals. 

Falsification of Claims

Falsification of claims encompasses a wide range of fraudulent activities intended to secure improper payment from AHCCCS. Examples include altering or fabricating medical records, intentionally submitting incorrect billing codes, double billing for the same service, offering or accepting kickbacks in exchange for referrals, and submitting wholly false information. Each of these practices constitutes fraud and undermines the integrity of the program.