Abuse by a Provider: Actions that are not wise business or medical practices and result in:
· unnecessary costs to the program
· payment for services that are not medically necessary
· not meeting professional standards for health care
Abuse by a Member:
Unnecessary costs to the program because of:
· providing false materials or documents
· leaving out important information
Any lie told on purpose that results in you or some other person receiving unnecessary benefits. This includes any act of fraud defined by Federal or State law.
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 Maricopa Health Plan provider.
· Giving incorrect information on your AHCCCS application.
Examples of Provider Fraud 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.
· Not meeting professional standards for health care.
How to Report Fraud and Abuse:
If you suspect a Maricopa Health Plan provider or member of fraud and abuse, please call the MHP Customer Care Center or AHCCCS at 1-800-962-6690 to report it.
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.