LEGAL GUIDE
Written by attorney Geoffrey Trachtenberg | Jun 30, 2011

It is Generally Unlawful for a Healthcare Provider to Bill An AHCCCS Enrollee

All AHCCCS registered healthcare providers must sign a Provider Participation Agreement ("PPA") with AHCCCS which, among other things, requires as a condition of its participation in the program that they to adhere to various federal and state laws and regulations. For example, Paragraph 6 of the standard PPA states: 6. The Provider shall comply with all federal, State and local laws, rules, regulations, standards and executive orders governing performance of duties under this Agreement, without limitation to those designated within this Agreement. Likewise, Paragraph 15 states: 15. The Provider shall not bill, nor attempt to collect payment directly or through a collection agency from a person claiming to be AHCCCS eligible without first receiving verification from AHCCCSA that the person was ineligible for AHCCCS on the date of service, or that services provided were not AHCCCS covered services. The Provider agrees to abide by Arizona Administrative Code R9-22-702 prohibiting the Provider from charging, collecting, or attempting to collect payment from an AHCCCS eligible person. Consistent with this contract provision, Ariz. Admin. Code § R9-22-702 states that an "AHCCCS registered provider shall not . . . . [c]harge, submit a claim to, or demand or collect payment from a person claiming to be an eligible person." In fact, pursuing a bill against an AHCCCS enrollee can trigger civil penalties of "three times the amount of the billing" and is expressly prohibited by ARS § 36-2903.01(L). When this occurs, it is appropriate to report the unlawful billing to the AHCCCS Office of Inspector General for further action, since the OIG considers such billing practices by AHCCCS providers to be "fraudulent." Indeed, this entire scheme is an outgrowth of federal regulations, 42 C.F.R. § 447.15, which prohibits billing AHCCCS enrollees.

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