chapter 17 – corporate compliance

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CHAPTER 17 – CORPORATE COMPLIANCE
17.0 – CORPORATE COMPLIANCE
Health Choice Integrated Care is responsible for ensuring that mechanisms are in place for the
prevention, detection and reporting of fraud and/or program abuse. All employees of providers must
be familiar with the types of fraud and/or program abuse that could occur during their normal daily
activities. Health Choice Integrated Care is responsible for adhering to the policies, procedures, and
initiatives found in the ADHS/DBHS BCC Operations and Procedures Manual.
ADHS/DBHS’ Bureau of Corporate Compliance (BCC) Program and Health Choice Integrated Care
incorporates Compliance Plan; Corporate Compliance Officer; a Corporate Compliance Committee;
effective training and education, communication, monitoring/auditing; and effective written policies
and procedures. Any person(s) found to be guilty for knowingly obtaining any benefit by means of false
or fraudulent pretenses, representations, promises or material omissions could be charged with a Class
2 Felony.
REPORTING FRAUD AND PROGRAM ABUSE INVOLVING TITLE XIX/XXI FUNDS
Pursuant to ACOM 103, immediately upon discovery of a suspected incident of fraud and/or program
abuse involving any Title XIX/XXI funds, including a suspected incident committed by Health Choice
Integrated Care and/or the provider will notify the AHCCCS Office of the Inspector General (OIG).
Listed below are the methods for reporting:
Online form: http://www.azahcccs.gov/fraud/reporting/reporting.aspx Email:
[email protected] Phone: 602-417-4193 or 602-417-4045 Fax: 602-417-4102
A copy of the referral, along with any and all supporting documentation, shall also be provided to
ADHS/DBHS Bureau of Corporate Compliance using one of the above methods.
REPORTING FRAUD AND PROGRAM ABUSE INVOLVING NON-TITLE XIX/XXI OR GRANT FUNDS
Health Choice Integrated Care is required to report all other instances of suspected fraud, waste
and program abuse involving all funding sources other than Title XIX/XXI to ADHS/DBHS/BCC
directly as provided in the BCC Operations and Procedures Manual or ADHS/DBHS/AHCCCS Policy.
Reports to ADHS/DBHS/BCC shall be completed in written format using the approved designated
ADHS/DBHS/BCC reporting form: Suspected Fraud and Program Abuse Report (English/Spanish).
When reporting fraud, waste or program abuse of Non-Title XIX/XXI funds or grant funds, the report
shall be submitted in a format which identifies and separates the amount(s) by each appropriate fiscal
year.
The reporting format should also identify the different funding streams for each dollar amount and
whether it was a claim or an encounter. The form may be submitted directly via any of the following
methods:
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Last Revised: October, 2015
Mail: Arizona Department of Health Services Division
of Behavioral Health Services Bureau of
Corporate Compliance 15 North 18th Avenue,
Suite 250 Phoenix, AZ 85007
Email: [email protected] Phone: (602) 364-3758 or 1-866-569-4927 Fax: (602) 364-3940
AHCCCS-OIG COMMUNICATIONS
Health Choice Integrated Care shall report to ADHS/DBHS BCC , within ten (10) days of notification, any
and all contact made by AHCCCS-OIG in reference to any open/closed fraud, waste and program abuse
case, a voluntary self-disclosure settlement and/or any other type of fraud, waste and program abuse
activity involving official communications by AHCCCS-OIG.
ADHS/DBHS BCC shall be advised of the final disposition of any case and/or settlement
agreement made between the contractor and/or provider and AHCCCS-OIG.
REPORTING FRAUD AND PROGRAM ABUSE TO HEALTH CHOICE INTEGRATED CARE
In addition to notifying ADHS or AHCCCS, providers must immediately notify Health Choice Integrated
Care of all suspected incidents of fraud or program abuse through one of the following methods:
Mail:
Health Choice Integrated Care
Attn: Corporate Compliance Officer
1300 S. Yale St., Flagstaff, AZ 86001
Email: [email protected]
Phone: 928-214-1178
STATE LAWS RELATING TO CIVIL OR CRIMINAL PENALTIES OR FALSE CLAIMS AND STATEMENTS
To prevent and detect fraud, waste, and abuse, many states have enacted laws similar to the FCA but
with state-specific requirements, including administrative remedies and relater rights. Those laws
generally prohibit the same types of false or fraudulent claims for payments for health care related
goods or services as are addressed by the federal FCA. For further information on specific state law
requirements, contact Health Choice Integrated Care’s Compliance Office.
Additional information on the Deficit Reduction Act and False Claims Act is available on the following
websites:
•
Deficit Reduction Act – Public Law 109-171
•
Arizona Revised Statutes (ARS):
o ARS 13-1802: Theft
o ARS 13-2002: Forgery
o ARS 13-2310: Fraudulent schemes and artifices
o ARS 13-2311: Fraudulent schemes and practices; willful concealment
o ARS 36-2918: Duty to report fraud AAC R9-22-1101, et seq.: Civil Monetary Penalties and
Assessment
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Last Revised: October, 2015
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