Medi-Cal fraud costs taxpayers millions of dollars each year
and can endanger the health of the community. In 1999, the
Department of Health Services (DHS) established the Medi-Cal
Fraud Prevention Bureau to detect, investigate, and resolve
fraud and abuse in the Medi-Cal Program.
Fraud
and abuse concerns may include:
- use
of benefits by non-covered persons,
- intentionally
misleading a person to select one health plan over
another
- charging
Medi-Cal beneficiaries for covered services,
- fabrication
and/or falsification of claims,
- charges
for benefits already included in a capitation payment,
and
- soliciting,
offering, and receiving of kickbacks, bribes, or rebates
|
Both
Santa Clara Family Health Plan and State Department of Health Services
(DHS) have established methods for objectively and systematically
evaluating and investigating potential fraud and / or abuse.
Its system is designed to detect potential fraud through the
auditing of claims, prior authorization requests, member and
provider complaints, and payment patterns to investigate potential
fraud through internal and external auditing, and to resolve
potential fraud cases through exoneration, the corrective
action process, or referral to law enforcement authorities.
We
appreciate your cooperation in fighting Medi-Cal fraud and
abuse. If you suspect someone of Medi-Cal fraud, please call
the DHS Medi-Cal Fraud Hotline at 1-800-822-6222. You may
also call the VP, Compliance at (408) 874-1880, or the Plan
Compliance Officer at (408) 874-1882 to report any suspected
cases of fraud and abuse. |
