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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)
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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.