We use an SIU to review and investigate reported concerns. The team performs back-end audits, which may lead to actions against those who commit fraud, waste or abuse, such as:
Corrective education and/or training
A stricter use review
Recovery of monies already paid
Civil and/or criminal suits
End of a provider agreement or other contracts
Some of the more common fraud, waste or abuse issues have to do with coding. These include unbundling, up-coding and the use of exclusion codes and add-ons without the primary Current Procedural Terminology (CPT®) code.* Another common issue is using a diagnosis or procedure code that doesn’t match the member’s age or gender. Other issues include:
Excessive use of units
Misuse of benefits
Claims for services that weren’t supplied
Conflicts of interest and self-referrals
Gifts received in exchange for directing Medicare and Medicaid patients to a business
Our vice president of Compliance and Regulatory Affairs has the duty and authority to carry out the terms of our program. Our providers must make all employees available for in-person interviews, consultations and grand jury proceedings. And for in-person pretrial conferences, hearings, trials and any other processes.
*CPT® is a registered trademark of the American Medical Association.
Aetna Better Health of Illinois is not responsible or liable for content, accuracy or privacy practices of linked sites or for products or services described on these sites. If you did not intend to leave our site, click or tap the "x" in the upper right-hand corner.
This link will take you to the main Aetna® Medicaid website (AetnaBetterHealth.com). Aetna Better Health of Illinois is not responsible or liable for this specific content.
This link will take you to the Aetna Better Health® of Illinois provider website. It contains information for health care professionals. If you don't want to leave the member site, click or tap the "x" in the upper right-hand corner.
This link will take you to the Aetna Better Health® of Illinois vendor website. It contains information for our vendors. If you don't want to leave the member site, click or tap the "x" in the upper right-hand corner.