Arizona Healthcare Insurance and AHCCCS Fraud

Lerner & Rowe Law Group
AHCCCS fraud

Accused of Arizona Healthcare Insurance or AHCCCS Fraud?

If you are being investigated for and face allegations of healthcare insurance fraud or AHCCCS fraud, or have been arrested for crimes of this nature, you need the experienced and aggressive representation of a Lerner and Rowe Law Group white collar crime lawyer. 

Early representation is key to help prevent charges from being filed. 

Contact our award-winning Arizona criminal defense team for a free, no obligation consultation. We have the proven experience and know-how to represent those facing serious healthcare insurance fraud or AHCCCS fraud charges and allegations in Arizona. 

What Is the AHCCCS?

AHCCCS (Arizona Health Care Cost Containment System) is the Arizona Medicaid program that is a state and federally funded program. AHCCCS offers a wide range of medical services and resources to include behavioral health services in/outpatient clinics. AHCCCS also offers limited coverage of rehabilitative services, home health care, and long term care services based on income and eligibility requirements to: 

  • Arizona residents
  • Members of the American Indian Health Program (AlliP-#999998)
  • Alaska Natives (“All AN”) 

More specifically, AHCCCS makes it possible for qualifying low-income Arizona residents to access healthcare programs and resources that they would otherwise never have been able to afford.

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AHCCCS also assigns an individual identification number (“Provider ID”) to uniquely identify Providers that register with AHCCCS. The Provider ID is also used to identify which Providers render a service to AHCCCS members and which Providers receive payment for service rendered to AHCCCS members.

What Are Current Healthcare Insurance and AHCCCS Fraud Allegations?

As you’ve seen in the news, allegations of healthcare insurance and AHCCCS fraud claim that individuals and organizations used fraudulent techniques to deceive the health care system in order to gain money and drugs from the State of Arizona and the federal government for their personal benefit.

Here are a few examples of these types of fraud cases currently being investigated and pursued in legal proceedings in Arizona.

Healthcare Provider Insurance Fraud 

Healthcare provider fraud is committed by: 

  • Double billing (billing for a per diem rate that covered a service and then billing again for the service provided by an outside entity)
  • Money laundering
  • Overcharging patients beyond the copay for fully covered services under a managed care contract
  • Ghost billing (billing for services provided to a non-existent patient)
  • Excessive billing (billing for services in excess of those actually provided)
  • Receiving illegal incentives for patient referrals to other providers (aka kickbacks)

Consumer Healthcare Insurance Fraud

Consumer healthcare insurance fraud is committed by generating and presenting falsified documents pertaining to:

  • Claims for payment or benefits
  • Applications for healthcare
  • Premiums paid under an insurance policy
  • Applications for a certificate of authority
  • The financial status of an insurer, reinsurer, or alleged insurer/reinsurer
  • Assisting or facilitating any of the aforementioned actions.

Organization AHCCCS Fraud  

Falsification of claims and services may include:

  • Altering documents
  • Incorrect coding
  • Double billing
  • Kickbacks
  • Submission of false data
  • Submission of claims for services/supplies not provided
  • Misrepresentation of services/supplies 
  • Substitution of services

Member AHCCCS Fraud 

Individual member AHCCCS fraud allegations may include:

  • Resource misrepresentation (transfer/hiding) 
  • Residency 
  • Household composition 
  • Citizenship status 
  • Unreported income 
  • Misrepresentation of medical condition 
  • Failure to report third party liability

What Are the Penalties for Healthcare Insurance and AHCCCS Fraud in Arizona?

Those convicted of committing healthcare insurance and AHCCCS fraud in Arizona may be punished at the state and federal levels. At the State level, it is common to see felony charges of conspiracy, money laundering, illegal control of an enterprise, fraudulent schemes, and theft. Recent cases prosecuted in Arizona have resulted in the forfeiture of millions of dollars and significant prison sentences. Each instance of fraud is also subject to different federal and civil penalties.

Penalties for Healthcare Insurance Fraud Committed in Arizona

The nature of federal felony charges varies, and they may encompass penalties outlined in Section 1128B of the Social Security Act which can include:

  • Maximum prison sentence of five years
  • Up to $10,000 in fines per fraudulent item or activity
  • $25,000 maximum fine
  • Up to $50,000 plus treble damages

AHCCCS Fraud Penalties

Federal AHCCCS fraud penalties fall under the False Claims Act (FCA). Penalties can also include a civil penalty or fine of $5,500 to $11,000 per act/per fraudulent bill. Other additional consequences are:

  • Incarceration
  • Fines
  • Treble damages 
  • Probation
  • Permanent mark on a criminal record

Get Aggressive Representation Against Arizona Healthcare Insurance or AHCCCS Fraud Charges

Being investigated for or accused of healthcare insurance or AHCCCS fraud is a serious matter that requires immediate legal representation. With the help of an aggressive healthcare insurance Fraud lawyer at Lerner and Rowe Law Group, you’ll better your chances of getting charges reduced, or even dismissed.

Contact the white collar criminal defense lawyers at Lerner and Rowe Law Group by phone at click here or a FREE online form to schedule a free healthcare insurance fraud case consultation.