Arizona Health Care Cost Containment System - Medicaid Fraud and Abuse Prevention, Detection, Investigation, and Recovery Processes

AHCCCS has established various processes to help detect Medicaid fraud and abuse but can do more. Specifically, AHCCCS should develop and implement a plan to regularly update its fraud training for eligibility caseworkers and continue to identify data analysis capabilities for fraud detection. AHCCCS also needs to enhance its processes for investigating potential fraud and abuse cases in a timely manner, including developing written prioritization procedures for fraud and abuse cases to ensure that the highest priority cases are worked first. Finally, AHCCCS needs to make several changes in its processes for recovering Medicaid payments made in cases of fraud or abuse, including establishing a formal collections program.