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Fraud, waste and abuse

Magellan Complete Care of Arizona takes every allegation of healthcare fraud, waste and abuse seriously. If you think a provider or someone else is committing fraud, waste or abuse, please report it. Learn how below.

What is fraud?

Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to him or herself or some other person.

What is waste?

Waste is the overutilization of services or practices that result in unnecessary costs.

What is abuse?

Abuse is payment for items or services when there is no legal right to that payment and it was not obtained by someone knowingly or purposely misrepresenting facts.

What is the difference between healthcare fraud and healthcare waste or abuse?

The difference between fraud and waste or abuse is whether or not someone did it on purpose. Fraud is intentionally lying. The person knows that the information is false. Waste and abuse involve certain actions that don’t make sense. Waste and abuse cause payment for services that are not covered by the plan.

Examples of fraud, waste and abuse:

Providers

  • Providing medical services that are not needed
  • “Up-coding” – charging for a more complex or expensive service than was given
  • Billing for services that were not provided
  • Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
  • Billing for rented medical equipment after it has been returned
  • Billing twice for the same service
  • Billing for more services than can be performed in one day
  • Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)

Members

  • Using another person’s name to get Medicaid services
  • Sharing a member ID card or using another person’s member ID card
  • Visiting several doctors to get multiple prescriptions
  • Lying to a care coordinator or someone else to try and get a service you don’t need
  • Paying a doctor cash for a prescription that is not needed
  • Making false documents by changing:
    • The date of service
    • Prescriptions
    • Medical records
    • Referral forms

Healthcare fraud and abuse prevention tips

You can help us stop fraud, waste or abuse by doing these things:

  • Review your paperwork from your plan, such as your Explanation of Benefits or Service Verification surveys (if received). Make sure the following information is correct:
    • Date of service
    • Type(s) of service(s) reported
    • Name of the provider billing for those services
  • Protect your insurance card and personal information at all times. Do not share it with others.
  • Count your pills when picking up a prescription.
  • Report anything that seems wrong to Magellan Complete Care of Arizona as soon as possible.

How can I report fraud, waste or abuse?

You can call the Magellan hotline to report fraud, waste and/or abuse. If you have questions about customer service issues (e.g. a claim not paid on time or the incorrect amount paid), call the Magellan Complete Care Corporate Compliance Hotline.

You can also report fraud by filling out the fraud, waste and abuse form online at www.azahcccs.gov/Fraud/ReportFraud/onlineform.aspx. Please give as much information as possible. You do not have to give your name. AHCCCS will not share your information with the provider.

Confidential hotline numbers (available 24 hours a day, 7 days a week):

Corporate Compliance Hotline: 800-915-2108

Compliance Unit Email: Compliance@MagellanHealth.com

Magellan Complete Care Special Investigation Unit: 877-269-7624

You can send an email to the Corporate Special Investigations Unit at SIU@MagellanHealth.com or call them at 800-755-0850.

You can also report fraud, waste or abuse concerns directly to the Arizona Health Care Cost Containment System (AHCCCS)/Office of Inspector General (OIG) at:

Office of the Inspector General

701 E Jefferson St, MD 4500

Phoenix, AZ 85034

 

Phone: 602-417-4193 (within Maricopa County)

888-ITS-NOT-OK (487-6686) (outside Maricopa County)

Email: AHCCCSFraud@azahcccs.gov

Website: www.azahcccs.gov/fraud/reportfraud/

Magellan is committed to doing business honestly, ethically and following all applicable laws and regulations. Magellan’s Corporate Compliance department provides guidance on code of conduct issues, corporate policy and/or laws and regulations.

Speak up for compliance

If you want to report a compliance concern or if you have any questions regarding Magellan’s compliance program, please contact Magellan’s Corporate Compliance department. There are two ways to report a concern:

  • Compliance Hotline: 1-800-915-2108. The hotline is available 24 hours a day, 7 days a week. Callers may choose to remain anonymous. All calls will be treated confidentially and investigated.
  • Email: Compliance@MagellanHealth.com