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
- 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.