Illinois Governor Initiates Fight Against Health Care Fraud Amid Growing Deficit

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As Illinois' finances continue to deteriorate and the budget crisis remains unsolved, the Rauner administration recently announced an initiative to focus on identifying and recouping health care fraud in Illinois. On April 5, 2016, Governor Rauner signed an Executive Order creating the Health Care Fraud Elimination Task Force (Task Force).

The Task Force is meant to bolster current efforts by developing and coordinating a more comprehensive, cross-disciplinary, data-driven approach to prevent and eliminate health care fraud, waste, and abuse in state-administered health care programs, like Medicaid. In a press release announcing the creation of the Task Force, the Rauner administration highlighted the more than $19 billion Illinois spent last year on state-administered health care programs and reiterated that the cost of such programs is inflated as a result of unchecked abuse.

Specific areas of focus for the Task Force include, among others:

  • Review of best practices currently used by the private sector, the federal government, and other states to prevent and reduce health care fraud, for purposes of determining whether those efforts should be implemented in Illinois;
  • Identify the forms of health care fraud currently occurring within state-administered health care programs as well as prevention and enforcement areas;
  • Assess the use of various data analytical approaches to better analyze and target oversight of state-administered health care programs;
  • Analyze patterns of system-wide fraud in order to recommend improved internal controls to state agencies to further prevent wrongdoing; and
  • Recover reimbursements wrongly paid to providers as a result of health care fraud, waste or abuse.

Led by the Executive Inspector General, the Task Force includes 11 other officers from state government, including Illinois' Chief Compliance Officer and Directors of the State Police Medicaid Fraud Control Unit, the Department of Healthcare and Family Services, the Department of Human Services and the Department on Aging.

Access the Executive Order here.

What Illinois Providers Should Know

  • While the Executive Order is light on details, Illinois providers should expect greater scrutiny of Medicaid claims, more frequent audits of past Medicaid billing and a general increase in actions to recoup reimbursements paid for by the state.
  • The Executive Order does not instruct the Task Force to focus on particular areas of fraud, waste, and abuse. Future audits of Illinois providers will likely expand beyond the typical reviews for medical necessity and include reviews related to cost reporting, improper claim submission and other unacceptable billing practices.
  • To prepare for this new initiative, providers should assess their current Medicaid billing policies and practices to determine compliance with applicable federal and state Medicaid regulations and conditions of participation. This includes ensuring that the documentation supports the medical services rendered by the provider and reimbursed for by the state. In the event that any deficient practices are identified, implement policies and procedures and provide appropriate training now to ensure that inappropriate claims are not submitted in the future.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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