Fraud, Waste and Abuse in Arizona

Molina seeks to uphold the highest ethical standards for our providers. We fully support the efforts of federal and state authorities in their enforcement of prohibitions of fraudulent practices by providers or other entities dealing with the provision of health care services.

Examples of Fraud, Waste and Abuse

Provider fraud, waste and abuse can include any and/or all of the following:

• Providing medical services that are not needed
• “Up-coding” – charging for a more complex or expensive service than was given
• Billing for services that were not provided
• Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
• Billing for rented medical equipment after it has been returned
• Billing twice for the same service
• Billing for more services than can be performed in one day
• Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)

Member fraud, waste and abuse can include any and/or all of the following:

• Using another person’s name to get Medicaid services
• Sharing a member ID card or using another person’s member ID card
• Visiting several doctors to get multiple prescriptions
• Lying to a care coordinator or someone else to try and get a service you don’t need
• Paying a doctor cash for a prescription that is not needed
• Making false documents by changing:
• • The date of service
  • Prescriptions
  • Medical records
  • Referral forms

Other Provider Crimes

• Soliciting or receiving payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients
• Referring Medicare or Medicaid patients to health care facilities in which or with which the physician has a financial relationship. (The Stark Law)
• Asking the patient to pay the difference between the discounted fees, negotiated fees and the provider's usual and customary fees

Reporting Fraud and Abuse

If you have concerns about possible fraud, waste and abuse, you can report your concerns by calling the Molina AlertLine to report fraud, waste and/or abuse. If you have questions about customer service issues (e.g. a claim not paid on time or the incorrect amount paid), call the Molina Healthcare Corporate Compliance Hotline.

You can also report fraud by filling out the fraud, waste and abuse form online. Please give as much information as possible. You do not have to give your name. AHCCCS will not share your information with the provider.

Confidential hotline numbers available 24 hours a day, 7 days a week:

AlertLine: (866) 606-3889

Online: www.molinahealthcare.alertline.com

Molina Complete Care Special Investigation Unit: (877) 269-7624

You can also report fraud, waste or abuse concerns directly to the Arizona Health Care Cost Containment System (AHCCCS)/Office of Inspector General (OIG) at:

Office of the Inspector General
701 E Jefferson St, MD 4500
Phoenix, AZ 85034

Phone: (602) 417-4193 (within Maricopa County)

(888) ITS-NOT-OK (487-6686) (outside Maricopa County)

Email: AHCCCSFraud@azahcccs.gov

Website: www.azahcccs.gov/fraud/reportfraud/

More provider resources