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Fraud, Waste and Abuse

IlliniCare Health takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste and abuse (FWA) program that complies with the State of Illinois and federal laws. To report FWA, call Provider Services at 866-329-4701 or our Fraud and Abuse hotline at 866-685-8664.

IlliniCare Health, in conjunction with its management company, Centene, successfully operates a Special Investigation Unite (SIU) that manages the review and investigation of reported concerns. IlliniCare Health performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system; please review the Billing and Claims section of this manual. 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 around eliminating the egregious action;
  • More stringent utilization review;
  • Recoupment of previously paid monies;
  • Termination of provider agreement or other contractual arrangement;
  • Civil and/or criminal prosecution; and
  • Any other remedies available to rectify.

Some of the most common FWA issues include:

  • 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
  • Conflicts of Interest;
  • Self-Referrals; and
  • Accepting gifts from a company, for example a DME company or pharmaceutical company, in exchange for directing your Medicare and Medicaid patients to use those companies

If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our free anonymous and confidential hotline at 866-685-8664. IlliniCare Health and Centene take all reports of potential fraud, waste and/or abuse very seriously and investigate all reported issues. IlliniCare Health and Centene has a no retaliation policy for anyone reporting a concern.

Authority & Responsibility

IlliniCare Health’s Vice President of Compliance and Regulatory Affairs has overall responsibility and authority for carrying out the provisions of IlliniCare Health’s compliance program. IlliniCare Health is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse.

The IlliniCare Health provider network will cooperate fully in making personnel and/or subcontractor personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials and in any other process, including investigations.