Visit our Compliance Resources webpage for a list of links to compliance resources available online.
Mission of Magellan of Arizona's Compliance Program
"To develop and implement mechanisms to prevent and detect fraud, waste and abuse in the Maricopa County behavioral health system through effective communication, training, review and investigation."
Confidentiality of Health Information
Magellan of Arizona recognizes the importance of privacy and confidentiality for our consumers, employees, and providers-it's a key principle of our business. All Magellan of Arizona employees understand and comply with the laws applicable to the protection of confidential health information. To that end, Magellan of Arizona has policies and procedures in place to address the protection and privacy of consumer information that is used or disclosed by Magellan of Arizona in any format.
Fraud and Abuse Overview
Fraud and Abuse is a serious crime that legitimately concerns all parties to our behavioral healthcare system -- insurers and premium-payers, government and taxpayers, and consumers and behavioral healthcare providers - and is a costly reality government and society cannot afford to overlook.
For Instance, on February 2002, the HHS-OIG reported that of the $191.8 billion in claims paid in 2001, 6.3% - amounting to $12.1 billion - should not have been paid due to erroneous billing or payment, inadequate provider documentation of services to back up the claims and/or were outright fraud.
In response to these realities, Congress - through the Health Insurance Portability and Accountability Act of 1996 (HIPAA) - specifically established health care fraud as a federal criminal offense, with the basic crime carrying a federal prison term of up to 10 years in addition to significant financial penalties.
Congress also mandated the establishment of a nationwide "Coordinated Fraud and Abuse Control Program," to coordinate federal, state and local law enforcement efforts against health care fraud.
The Deficit Reduction Act (DRA) was passed by Congress in 2005. The DRA became effective January 1, 2007 and requires all entities in receipt of $5 million or more in annual Medicaid payments to establish and disseminate written policies that provide detailed information about the Federal False Claims Act, applicable state false claims laws including civil or criminal penalties for making false claims and statements, the "whistleblower" protections afforded under such laws and the role of such laws in preventing and detecting fraud, waste and abuse.
To ensure early detection and investigation, Magellan of Arizona has established multiple channels through which employees, consumers, providers, and other entities may report suspected fraud, waste or abuse. Magellan of Arizona will also disseminate written policies to all employees, contractors, agents, or other parties which or who, on behalf of Magellan of Arizona, furnish or otherwise authorize the furnishing of, Medicaid behavioral health care items or services; perform billing or coding functions; or are involved in the monitoring of health care provided by the entity.
What are Waste, Fraud and Abuse?
Billing errors are often referred to as waste. A billing error is an incorrect submission of a claim due to an honest mistake. Any number of things can cause a billing error. These include inexperienced office staff, coding illiteracy, staff turnover or a simple keying error. These are unintentional errors that could cause overpayment. In most cases, billing errors can be corrected through provider education/training.
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the person or some other person. It includes any act that constitutes fraud under applicable Federal or State Law.
Provider practices that are inconsistent with sound fiscal business, or medical practices, and result in an unnecessary cost to the AHCCCS program, the State of Arizona or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes behavioral health recipient practices that result in unnecessary costs to the AHCCCS program and/or the State of Arizona
Fraud and Abuse Criteria
The following is list of criterion used by Magellan of Arizona to determine whether fraud or abuse is suspected and should be reported to AHCCCS - Office of Program Integrity and/or ADHS/DBHS - Office of Program Integrity. At least one of the following criteria must be met:
- Evidence of knowing and intentional;
- Duplicate billings;
- Upcoding - billing for more expensive services or procedures than were actually provided or performed;
- Unbundling - practice of submitting bills piecemeal or in fragmented fashion to maximize reimbursement;
- Misrepresentation of services - misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining payment;
- Billing for services not rendered;
- Evidence of false or altered documents;
- Evidence of missing documentation;
- Evidence of irregularities following sanctions for same problem;
- Evidence of unlicensed or excluded professional or facility at time of services;
- Evidence of management knowledge of fraudulent activity;
- Reports of material irregularities by more than one reliable source.
And all of the following criteria must be met:
- Pattern of occurrence of irregularities;
- Actual loss to a governmental program;
- Loss would be considered material for nature and type of activity and provider.
Or at least one of the following criteria is met:
- Direct personal knowledge of fraudulent activity by known reliable individual;
- Magellan of Arizona documented audit findings that show suspected fraud;
- Report showing evidence of suspected fraud from another government or law enforcement agency.
To ensure early detection and investigation, Magellan of Arizona has established multiple channels through which employees, consumers, providers, and other entities may report suspected fraud, waste or abuse.
- Special Investigations Unit Hotline: (800) 755-0850
- Special Investigations Unit E-mail: SIU@magellanhealth.com
- Corporate Compliance Hotline: (800) 915-2108
- Phyllis Knox, Chief Compliance Officer
Magellan of Arizona
Phone: (602) 572-5914
Fax: (800) 424-4798
- Adam Fields, Arizona Fraud and Abuse Manager
Magellan of Arizona
Phone: (602) 572-5917
Fax: (800) 424-4798