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Healthcare Insurance and AHCCCS Fraud

Healthcare Insurance and AHCCCS Fraud

Healthcare Insurance Fraud is a type of White Collar Crime. This fraud is committed when a healthcare provider or a consumer intentionally submits, or causes another person to submit, false information toward determination of payment of health care benefits.

A healthcare provider may commit Healthcare Insurance Fraud by:

  • Billing for services not provided
  • Falsifying patient diagnosis in order to justify procedures, surgeries or tests that are not medically necessary
  • Misrepresenting procedures performed in order to obtain payment for services not covered by the policy, such as cosmetic procedures
  • Upcoding, to bill for higher paying procedures than those actually performed
  • Accepting kickbacks for referring patients to other providers
  • Unbundling, to allow for multiple billings for stages of a procedure actually performed in one procedure
  • Waiving patient deductibles or copays and overbilling for these
  • Billing patients more than the amount of the copay for prepaid or paid-in-full services covered by the benefit plan under a managed care contract

Arizona law specifies in Arizona Revised Statute ARS 20-263 that it is an unlawful and fraudulent activity for a person to do the following acts which constitute Healthcare Insurance Fraud:

  • Create and produce documents with untrue statements related to:
    • A healthcare application
    • Insurance policy rating
    • Payment or benefit claim
    • Premiums paid through an insurance policy
    • Payments made pursuant to terms of an insurance policy
    • An application for a certificate of authority
    • The financial condition of an insurer, reinsurer or purported insurer or reinsurer
    • To aid or abet in any of the above

Healthcare Insurance Fraud committed in Arizona may be punished at the state and federal levels. If you are being investigated for Healthcare Insurance Fraud or have been arrested for crimes of this nature, you need the experienced and aggressive representation of DM Cantor. Having early representation is important for in order to help prevent charges from being filed.

Federal felony charges vary. These federal crimes may include penalties under Section 1128B of the Social Security Act:

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


AHCCCS is the Arizona Health Care Cost Containment System. This is Arizona’s healthcare agency providing Medicaid and other healthcare programs to underserved state residents. AHCCCS is known for filling the gap between the expense of healthcare and populations that cannot afford to get the medical care they need. As part of AHCCCS, residents of Arizona who meet income requirements and other parameters are able to gain medical programs and resources they would otherwise never be able to afford.

Types of Arizona AHCCCS Fraud

The Office of the Inspector General audits and investigates anyone suspected of defrauding or attempting to defraud the AHCCCS programs. These investigations may be into organizations allegedly enacting the fraud, or the investigation may solely involve individuals. The Office of the Inspector General serves the public further by recovering overpayments, issuing administrative sanctions or referring suspected cases of fraud for criminal prosecution.

Some types of AHCCCS fraud alleged against its members include:

  • Eligibility fraud
  • Resource misrepresentation
  • Residency issues
  • Household composition misrepresentation
  • Citizenship status misrepresentation
  • Unreported income
  • Misrepresentation of health condition
  • Failure to report third-party liability

Some types of AHCCCS fraud alleged against organizations include:

  • Falsification of claims, such as through the following acts:
    • Alteration
    • Incorrect coding
    • Double billing
    • Kickbacks
    • Submission of false data
    • Fraudulent enrollment
  • Falsification of services includes the following acts:
    • Billing fraud
    • Misrepresentation of provided or non-provided services
    • Substitution of services

Potential Penalties for AHCCCS Fraud in Arizona

When you are accused of or arrested for AHCCCS fraud, you need highly skilled legal representation to keep you from suffering the worst consequences of the crimes you are being investigated for by the Office of the Inspector General.

Federal Penalties of AHCCCS Fraud as a violation of the False Claims Act include a civil penalty or fine of $5500 to $11,000 per act/per fraudulent bill. There are also other consequences that may include:

  • Permanent listing of the crime on your criminal record
  • Incarceration
  • Probation
  • Fines
  • Triple damages (ie. 3 times the alleged fraud total)
  • Other penalties

Arizona Healthcare Insurance Fraud Is both a Criminal and Civil Matter

In Arizona, you may be charged civilly and criminally for Healthcare Insurance Fraud, just as your crimes may be prosecuted at the state and federal levels. Civil repercussions of Healthcare Insurance Fraud arise from the filing of false claims such as:

  • Double billing
  • Altering prescription costs
  • Altering medical records
  • Submitting bills for services that were not provided or needed
  • Providing kickbacks for patient referrals or over-ordering
  • Medical equipment fraud
  • Ordering unneeded medical tests
  • Prescribing unneeded or too much medication

Have You Been Accused of Healthcare Insurance or AHCCCS Fraud?

If you have been accused of Healthcare Insurance or AHCCCS Fraud or are being investigated for these crimes, you need the help of the aggressive Healthcare Insurance Fraud attorneys of DM Cantor. The earlier in your case that you secure representation by an aggressive attorney, the better your chances of getting charged reduced, or even dismissed.

The lawyers of DM Cantor are aggressive and thorough in their defense of clients accused of Healthcare Insurance Fraud, as well as all other White Collar Crimes.

With the highest possible rating by Martindale Hubbell®, and as an AV ® rated law firm, DM Cantor has the legal skill you need on your side. The firm is also listed in the Criminal Law Section of the Bar Register of Preeminent Lawyers®. Call DM Cantor at 602-307-0808 or Contact Us for a Free Case Consultation.

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