CountyCare - Fraud, Waste and Abuse System

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Fraud, Waste and Abuse System

CountyCare takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste, and abuse program that complies with Illinois and federal laws. CountyCare’s fraud, waste and abuse program performs front and back end audits to ensure compliance with billing regulations.

A Special Investigation Unit (SIU) performs back end audits which, in some cases, may result in taking the appropriate actions against those who, individually or as a practice, commit fraud, waste and/or abuse, including but not limited to:

  • Remedial education and/or training to attempt to eliminate the egregious action
  • Increasingly stringent utilization review
  • Recoupment of previously paid monies from a provider/practice
  • Termination of provider agreement or other contractual arrangement
  • Civil and/or criminal prosecution
  • Any other remedies available to rectify the issue identified

Some of the most common fraud, waste and abuse issues identified are:

  • Unbundling of codes
  • Up-coding
  • Add-on codes without primary CPT
  • Diagnosis and/or procedure code not consistent with the member’s age/gender
  • Use of exclusion codes
  • Excessive use of units
  • Misuse of benefits
  • Claims for services not rendered

If you suspect or witness a provider inappropriately billing for Medicaid services or a member receiving inappropriate services, please call our anonymous and confidential hotline at 844-509-4669. CountyCare takes all reports of potential fraud, waste and/or abuse very seriously and will investigate all reported issues.

For more information on CountyCare’s Fraud, Waste and Abuse system, please see the Provider Manual.