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DOCUM3NT RESURE
05115 - [B0725639]
Further Improvements Needed in Investigations of Medicaid Fraud
and Abuse in Illinois. RD-78-46; B-1614031(4). a,-rch 10g 1978.
Released larch 13, 1978. 42 pp. + 2 appendices (2 pp.).
Report to the Congress; by Elmer B. Staats, Comptroller Genera'1
Issue Area: Health Programs: Fraud ati Abese In the Financing
Proqrat (1206).
Contact: Human Resources Div.
Budqet Function: Health: F ealth Care Services (551).
organization Concerned: Department of Health, 3ducation, and
HelfLre; Health Care Fiaazcinq Administration; Illinois.
Conqressional Relevance: Congress.
Authority: Social Security Act, as amended (42 L.S.c. 1395). -45
C.F.R. 250. 18 U.S.C. 286. 31 U.S.C. 231. P.L. 9*-505. E.L.
95-142.
A followup review was conducted of Medicaid fraud and
abuse in the State of illinois, with emphasis cn: (1) Department
of Health, Education, and Welfare (REW) efforts tj strengthen
its oversight role in identifying and proventing Medicaid fraud;
and (2) Illinois actions to better deal with Medicaid fraud and
abuse and its conputerised system for processing fMedicaid
claims. Findings/Conclusions: Some probleas which BENes nev
Health Care Financing Adiiistration should attempt to eliminate
involve: communication to medicate of information on providers
terminated from Redicaid because of impropeL activities; the
inability of HEN headquarters to assqre that each region makes
scheduled reviews uf State efforts to control Medicaid fraud and
abuse; and limited HEW evaluation of, and assistance to,
Illinois' efforts to identify providers involved in Madicaid
fraid. During 19770 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. such of the money recovered by
Illinois was from payments for duplicate or other unallouiale
billings, and most of Illinoist efforts pertained to payments
made before 1974. Recoemendatiou,: The Secretary of BEV should
direct the Health Care Financing Administratics to require that:
information on terminated providers is exchanged between
Medicare and Medicaid so that providers are terminated from both
proqrams: and each REV regional office reviews State efforts to
control fraud and abuse. With respect to Illinois, HEV needs to
make sure that the State routinely reviews current information
on all major provider groups and revievs the feasibility of
coordinating reviews of Medicaid fraud and abuse with State
licensing agencies to help determine if providers' medical
licenses should be revoked. (RRS)](ViewImageLocal?handle=hein.gao/gaobaawsl0001&div=1&collection=&method=preview&ext=.png&size=3)