Fraud and Abuse Reporting

SCAN supports efforts to detect, prevent and report fraud and abuse within the AHCCCS and Medicare programs. These efforts are consistent with our mission to provide care to those with special needs while exercising sound fiscal responsibility. Management of limited resources is a key part of this responsibility.

Examples of actions that are reportable to the state and federal investigative agencies include: physical or sexual abuse of members, improper billing and coding of claims, pass through billing, billing for services not rendered or raising fees for Medicaid and Medicare patients to allowable amounts if these fees are not billed to other patients. In addition, unbundling and up coding may be construed as fraud if a pattern is found to exist.

Member fraud is also reportable and examples include: use of another member’s identification to obtain services, fraudulent application for eligibility, sale of durable medical equipment while on loan to members and prescription fraud. The following laws are applicable to providers and providers must train their employees to be familiar and comply with these laws.

SCAN is required to report cases of suspected fraud or abuse to the AHCCCS Office of Program Integrity and /or the Office of the Inspector General (OIG) or the Justice Department Civil Division or the U.S. Attorney. Other agencies may have involvement in cases of criminal activity or abuse.

Anyone who suspects member or provider fraud or abuse must report it either to the SCAN Compliance Department at (602) 778-3300, or directly to the State hotline at 1-(888) IT’S NOT OK or 1-(888) 487–6686, or on-line at:

http://www.azahcccs.gov/fraud/Default.aspx