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Fraud, waste and abuse 

Aetna Better Health® of Illinois takes the detection, investigation and prosecution of fraud and abuse seriously. We have a fraud, waste and abuse program that complies with the state of Illinois and federal laws.

Whom do I send my reports to?

If you suspect fraud, waste and abuse related to Aetna Better Health of Illinois, you can:

Call our hotline

Report suspected cases to the Aetna Better Health of Illinois Fraud, Waste and Abuse hotline at 1-866-536-0542 (TTY: 711).

Call Provider Services

Report suspected cases to Aetna Better Health of Illinois Provider Services at 1-866-329-4701 (TTY: 711).

Aetna Better Health of Illinois Special Investigation Unit (SIU)

Aetna Better Health of Illinois Special Investigation Unit (SIU)

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

Common issues

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 

Authority and responsibility 

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.