CountyCare takes the detection, investigation, and prosecution of fraud, waste, abuse, mismanagement and misconduct very seriously. CountyCare’s Program Integrity efforts operate under policies, procedures and guidelines to ensure compliance with all Illinois and federal laws and regulations.
CountyCare’s Program Integrity efforts include performing front and back end audits to ensure provider compliance with billing regulations.
A Special Investigation Unit (SIU) performs routine internal monitoring and back end auditing of program integrity compliance risks and investigations of any issues identified. CountyCare promptly responds to compliance issues detected, including the correction of issues through education and the implementation of corrective action plans in compliance with program integrity-related requirements. In some cases, this may result in taking the appropriate actions against those who, individually or as a practice, commit fraud, waste, abuse, mismanagement or misconduct , including but not limited to:
- Remedial education and/or training to attempt to eliminate the egregious action
- Increasingly stringent utilization review process
- Recoupment of previously paid monies from a provider/practice
- Termination of provider agreement or other contractual arrangements
- Civil and/or criminal prosecution
- Any other remedies available to rectify the issue identified
The CountyCare SIU may also conduct prepayment reviews of provider claims as a result of suspected fraud, waste, abuse, mismanagement or misconduct, which may require the provider to submit additional records or documentation.