About MagellanofAZ

Regional Behavioral Health Authority

Magellan of Arizona Ethics and Code of Conduct

Ethical Responsibility of All Magellan of Arizona Employees

As a Magellan of Arizona employee, you have an obligation to be honest in all your dealings with providers, customers, consumers, vendors, third parties and each other. You must know and comply with applicable laws and Magellan's policies and procedures. Claims of ignorance, good intentions, or use of poor judgment are not acceptable excuses for noncompliance. Maintaining ethical standards is everyone's responsibility. If you know of a problem or issue, you cannot remain silent. You must step forward to help solve it!

Ethical Leadership Responsibility of All Magellan of Arizona Managers

Leadership requires setting a personal example of high ethical standards in the performance of your job. It's up to you, as a manager, to set the tone for Magellan of Arizona and your employees. You must take responsibility for the actions of your employees. You are accountable for making sure that your employees understand and apply the ethical standards set forth in the Magellan Health Services Compliance Handbook. This is accomplished through adequate training, supervision, communication and awareness. You must be open to your employees' questions and diligently act on their concerns.

If you are confronted with a questionable ethical situation, answering the following questions can help you determine a response or course of action:

• Does it comply with applicable law and Magellan of Arizona's policies and procedures?
• How would it look to your family, friends, colleagues, employees, our providers, consumers, shareholders and the general public?
• Would you want this done to you?
• If you know it's wrong and/or unethical, don't do it.
• If you are not sure, ask. Keep asking until you get an answer that makes sense.

Our Commitment To An Ethical WorkPlace

The highest standards of ethics and integrity are required of every Magellan of Arizona employee. We strive to deliver high quality results for our consumers and providers. All Magellan employees are required to:

• Treat all behavioral health consumers with dignity and respect, always focusing on the best interest of the consumer;
• Set an example through their behaviors;
• Avoid situations that may result in conflicts of interest with Magellan of Arizona and its business, i.e., avoiding situations where personal interests conflict or could be perceived as conflicting with Magellan's business interests;
• Market Magellan of Arizona's services in compliance with applicable state and federal requirements and forego any business that can only be obtained by improper or illegal means;
• Create a workplace that is free from harassment, drugs, narcotics, alcohol and discriminatory practices;
• Comply with all applicable laws and Magellan's policies, including, but not limited to, those addressing employees' health, safety and welfare in the workplace;
• Be familiar with insider trading laws (i.e., inside information cannot be used for personal gain);
• Comply with applicable state and federal law and cooperate with any reasonable demands made in the course of a government investigation; and
• Be familiar with Magellan of Arizona's policies on document retention and confidentiality, and abide by all applicable state and federal laws, regulations and contractual requirements regarding the retention of records.

Confidentiality of Health Information

Magellan of Arizona recognizes the importance of privacy and confidentiality for our consumers, employees, and providers-it's a key principle of our business. All Magellan of Arizona employees are required to understand and comply with the laws applicable to the protection of confidential health information. To that end, Magellan of Arizona has policies and procedures in place to address the protection and privacy of consumer information that is used or disclosed by Magellan of Arizona in any format.

Mission of Magellan of Arizona's Compliance Program

"To develop and implement mechanisms to prevent and detect fraud, waste and abuse in the Maricopa County behavioral health system through effective communication, training, review and investigation."

Fraud and Abuse Overview

Fraud and Abuse is a serious crime that legitimately concerns all parties to our behavioral healthcare system -- insurers and premium-payers, government and taxpayers, and consumers and behavioral healthcare providers - and is a costly reality government and society cannot afford to overlook.

For Instance, on February 2002, the HHS-OIG reported that of the $191.8 billion in claims paid in 2001, 6.3% - amounting to $12.1 billion - should not have been paid due to erroneous billing or payment, inadequate provider documentation of services to back up the claims and/or were outright fraud.

In response to these realities, Congress - through the Health Insurance Portability and Accountability Act of 1996 (HIPAA) - specifically established health care fraud as a federal criminal offense, with the basic crime carrying a federal prison term of up to 10 years in addition to significant financial penalties.

Congress also mandated the establishment of a nationwide "Coordinated Fraud and Abuse Control Program," to coordinate federal, state and local law enforcement efforts against health care fraud.

The Deficit Reduction Act (DRA) was passed by Congress in 2005. The DRA became effective January 1, 2007 and requires all entities in receipt of $5 million or more in annual Medicaid payments to establish and disseminate written policies that provide detailed information about the Federal False Claims Act, applicable state false claims laws including civil or criminal penalties for making false claims and statements, the "whistleblower" protections afforded under such laws and the role of such laws in preventing and detecting fraud, waste and abuse.

To ensure early detection and investigation, Magellan of Arizona has established multiple channels through which employees, consumers, providers, and other entities may report suspected fraud, waste or abuse. Magellan of Arizona will also disseminate written policies to all employees, contractors, agents, or other parties which or who, on behalf of Magellan of Arizona, furnish or otherwise authorize the furnishing of, Medicaid behavioral health care items or services; perform billing or coding functions; or are involved in the monitoring of health care provided by the entity.

What are Waste, Fraud and Abuse?

Waste
Billing errors are often referred to as waste. A billing error is an incorrect submission of a claim due to an honest mistake. Any number of things can cause a billing error. These include inexperienced office staff, coding illiteracy, staff turnover or a simple keying error. These are unintentional errors that could cause overpayment. In most cases, billing errors can be corrected through provider education/training.

Fraud
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the person or some other person. It includes any act that constitutes fraud under applicable Federal or State Law.

Abuse
Provider practices that are inconsistent with sound fiscal business, or medical practices, and result in an unnecessary cost to the AHCCCS program, the State of Arizona or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes behavioral health recipient practices that result in unnecessary costs to the AHCCCS program and/or the State of Arizona

Fraud and Abuse Criteria

The following is list of criterion used by Magellan of Arizona to determine whether fraud or abuse is suspected and should be reported to AHCCCS - Office of Program Integrity and/or ADHS/DBHS - Office of Program Integrity. At least one of the following criteria must be met:

• Evidence of knowing and intentional;
• Duplicate billings;
• Upcoding - billing for more expensive services or procedures than were actually provided or performed;
• Miscoding;
• Unbundling - practice of submitting bills piecemeal or in fragmented fashion to maximize reimbursement;
• Misrepresentation of services - misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining payment;
• Billing for services not rendered;
• Evidence of false or altered documents;
• Evidence of missing documentation;
• Evidence of irregularities following sanctions for same problem;
• Evidence of unlicensed or excluded professional or facility at time of services;
• Evidence of management knowledge of fraudulent activity;
• Reports of material irregularities by more than one reliable source.

And all of the following criteria must be met:

• Pattern of occurrence of irregularities;
• Actual loss to a governmental program;
• Loss would be considered material for nature and type of activity and provider.

Or at least one of the following criteria is met:

• Direct personal knowledge of fraudulent activity by known reliable individual;
• Magellan of Arizona documented audit findings that show suspected fraud;
• Report showing evidence of suspected fraud from another government or law enforcement agency.

To ensure early detection and investigation, Magellan of Arizona has established multiple channels through which employees, consumers, providers, and other entities may report suspected fraud, waste or abuse.

• Special Investigations Unit Hotline: (800) 755-0850
• Special Investigations Unit E-mail: SIU@magellanhealth.com
• Corporate Compliance Hotline: (800) 915-2108
• Phyllis Knox, Chief Compliance Officer
  Magellan of Arizona
  Phone: (602) 572-5914
  Fax: (800) 424-4798
• Adam Fields, Arizona Fraud and Abuse Manager
  Magellan of Arizona
  Phone: (602) 572-5917
  Fax: (800) 424-4798

Magellan's Corporate Governance - Code of Conduct