Further Improvements Needed in Investigations of Medicaid Fraud and Abuse in Illinois

HRD-78-46: Published: Mar 10, 1978. Publicly Released: Mar 10, 1978.

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A followup review was conducted of Medicaid fraud and abuse in the State of Illinois, with emphasis on: (1) Department of Health, Education, and Welfare (HEW) efforts to strengthen its oversight role in identifying and preventing Medicaid fraud; and (2) Illinois actions to better deal with Medicaid fraud and abuse and its computerized system for processing Medicaid claims.

Some problems which the new HEW Health Care Financing Administration should attempt to eliminate involve: (1) communication to Medicare of information on providers terminated from Medicaid because of improper activities; (2) the inability of HEW headquarters to assure that each region makes scheduled reviews of State efforts to control Medicaid fraud and abuse; and (3) limited HEW evaluation of, and assistance to, Illinois' efforts to identify providers involved in Medicaid fraud. During 1977, Illinois referred 60 providers for prosecution, stopped 70 from participating in Medicaid, recovered $6 million in erroneous payments, and established a computerized system for identifying providers who most likely defrauded or abused the program. Much of the money recovered by Illinois was from payments for duplicate or other unallowable billings, and most of Illinois' efforts pertained to payments made before 1974.

Recommendation for Executive Action

  1. Status: Closed

    Comments: Please call 202/512-6100 for additional information.

    Recommendation: The Secretary of HEW should direct the Health Care Financing Administration to require that: information on terminated providers is exchanged between Medicare and Medicaid so that providers are terminated from both programs; and each HEW regional office reviews State efforts to control fraud and abuse. With respect to Illinois, HEW needs to make sure that the State routinely reviews current information on all major provider groups and reviews the feasibility of coordinating reviews of Medicaid fraud and abuse with State licensing agencies to help determine if providers' medical licenses should be revoked.

    Agency Affected:

 

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