Section 101.50  Reporting Suspected Fraud or Abuse

a)         Any suspected fraud or abuse related to the Medical Assistance, KidCare, Child Support Enforcement, Transitional Assistance, Aid to the Aged, Blind and Disabled, Temporary Assistance to Needy Families, Food Stamp and Child Care Programs, and all other programs administered by the Department or by the Department of Human Services as successor agency to the Department, should be reported:

1)         in person or by U.S. Mail to the Office of Inspector General, Department of Public Aid, 404 North Fifth Street, Springfield, Illinois 62702;

2)         or by:

A)        telephone to the Office of Inspector General at 217/524-7658; or

B)        toll free telephone to the Medicaid and Welfare Fraud Hotline at 800/252-8903; or

C)        e-mail at oigwebmaster@mail.idpa.state.il.us.

b)         Referrals

1)         Referrals of suspected fraud or abuse on the part of 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 30 calendar days after receipt of the referral.

c)         Evaluations

1)         All referrals of suspected fraud or abuse will be evaluated within 60 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)        When the evaluation identifies possible criminal or civil fraud violations of the Medical Assistance Program or the KidCare Program by a medical provider or contractor, the referral shall be sent to the Medicaid Fraud Control Unit of the Illinois State Police for its 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.

(Source:  Added at 26 Ill. Reg. 2039, effective February 1, 2002)