ARIZONA, USA — It's been a year since a massive rehab scam that preyed on Native American communities and cost taxpayers roughly $2.8 billion came to light.
Of the 304 medical providers suspended from billing Arizona's Medicaid system, AHCCCS, on credible allegations of fraud, only 20 have been allowed to resume billing. For the most part, the system has been more focused on stepping up internal scrutiny.
AHCCCS Director Carmen Heredia said they've made sweeping reforms that will now provide "a level of quality that should have been there all along."
One of the main goals was to expand oversight within the system. Previously, AHCCCS allowed providers to bill on behalf of third parties and file claims for services rendered before the provider was registered — two of the biggest ways the scam played out, Heredia said.
That's no longer the case. The reforms set specific rates, thresholds and prepayment reviews. Additionally, AHCCCS has stepped up their identity verification security. Now, providers need to verify a photo ID directly through the AHCCCS online web portal, giving a clear picture of who is billing the system.
For members of managed care health plans, switching to the American Indian Health Program can no longer be done over the phone — another common scam tactic.
"We found that many individuals were coached to say they were American Indian when they in fact were not. We're asking for that switch to happen in person," Heredia explained.
Heredia acknowledged that the reform process has been a lengthy one and many providers felt stuck in investigative limbo over the last year. She hopes that the recent addition of over 80 full-time positions within the organization will speed up the process.
"The wait times are real because of the added scrutiny," Heredia said. "We're working on releasing some of those added bottlenecks with the staff that we've added and the technology we have in place."
The 20 providers were allowed to resume billing because new information was presented to AHCCCS that dispelled previously credible fraud allegations, Heredia said. She doesn't have a window for how long the investigations will take but is confident that the reforms are a big step in the right direction.
"The expectation has always been that you serve the American Indian population," Heredia said. "That is explicitly required. If you're an AHCCCS provider, you serve this population."
To fight future attempts at fraud and exploitation, AHCCCS has launched a humanitarian outreach campaign to the 22 federally recognized Tribes in Arizona. You can find more information on AZAHCCCS.gov/TribalResources
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