Reporting Suspected Fraud or Abuse

Section 101 Section 101.50  Reporting Suspected Fraud or Abuse a)         Any suspected fraud or abuse related to the Medical Assistance, Children's Health Insurance, Covering All Kids Health Insurance, Child Support Enforcement,  Aid to the Aged, Blind and Disabled, Temporary Assistance to Needy Families, SNAP and Child Care Programs, and other programs administered by the Department of Human Services, the Department on Aging, or the Department of Healthcare and Family Services, should be reported to the Office of the Inspector General (HFS-OIG): 1)         in person or by U.S. Mail to the Office of Inspector General, Department of Healthcare and Family Services, 2200 Churchill Road, A-1, Springfield, Illinois 62702; 2)         or by: A)        toll free telephone to the Office of Inspector General at 1-844-453-7283 (1-844-ILFRAUD); or B)        e-mail at hfs.oig.fraudhotline@illinois.gov; or C)        online at: www.illinois.gov/hfs/oig . b)         Referrals 1)         Referrals of suspected fraud or abuse, as explained in subsection (a), by providers, contractors, State or other governmental employees, recipients of services or any other person will be accepted. 2)         Referrals may be made anonymously. 3)         All referrals, other than anonymous referrals, will be acknowledged, either in writing, by telephone, by e-mail or in person, within 45 calendar days after receipt of the referral. c)         Evaluations 1)         All referrals of suspected fraud or abuse will be evaluated within 90 calendar days after receipt of the referral to determine what, if any, follow up action is appropriate. 2)         Factors considered during the evaluation of any referral include, but are not limited to: A)        source of the allegation; B)        quality of the evidence of wrongdoing; C)        potential loss to the program; and D)        availability of investigative and other resources necessary for successful follow up on the referral. 3)         Follow up actions include, but are not limited to, the following measures: A)        If the HFS-OIG's evaluation identifies possible criminal or civil fraud violations of the Medical Assistance Program or the Children's Health Insurance Program or the Covering All Kids Health Insurance Program by a medical provider or contractor, then a referral will be sent to the Medicaid Fraud Control Unit of the Illinois State Police for review for possible criminal investigation. B)        When the evaluation identifies possible criminal or civil fraud violations of any program by a recipient of services or other private citizen and is eligible for follow up action, the Office of Inspector General may initiate an investigation.  Should the investigation establish evidence of a criminal or civil fraud violation, the case may be referred to the appropriate United States Attorney, the Office of Attorney General or the appropriate State's Attorney for prosecutorial consideration. C)        When the evaluation identifies possible administrative violation and is eligible for follow up action, the Office of Inspector General may initiate a review to determine the appropriate administrative action.  Administrative actions include, but are not limited to: i)          claims analysis; ii)         audit; iii)        peer review; iv)        recipient restriction; v) eligibility review; or vi) administrative hearing.