Office of Inspector General

The Office of Inspector General (OIG) safeguards AHCCCS program integrity by preventing, detecting, investigating, and recovering improper payments due to fraud, waste, and abuse (FWA). As a designated criminal justice agency, OIG conducts both criminal and civil investigations and collaborates with law enforcement and other agencies.

Core Responsibilities:

• Investigates fraud and abuse across AHCCCS programs.
• Conducts audits and data-driven reviews.
• Coordinates with law enforcement and regulatory bodies.
• Recovers improper payments and enforces compliance.

OIG Sections:

1. Provider Compliance Section (PCS)
   Investigates provider fraud through audits and referrals. Includes:
• Provider Compliance Unit
• Pharmacy Fraud Investigative Team
• Fee-for-Service Team
2. Member Compliance Section (MCS)
   Ensures member compliance through:
• Member Criminal Investigations Unit (MCIU)
• Fraud Prevention Unit (FPU)
3. Program Integrity Team (PIT)
   Uses data mining and utilization reviews to detect fraudulent billing trends.
4. Fraud Support and Recovery (FSR)
   Oversees corporate compliance and conducts:
• Provider audits
• Collections
• Performance improvement projects
5. Forensic Fraud Unit (FFU)
   Specializes in complex financial and corporate healthcare fraud investigations, offering training and support to enhance investigative efficiency.