Stopping healthcare fraud, waste, and abuse
Healthcare fraud is a serious issue that contributes to the skyrocketing cost of medical care. It's estimated that Medicare and Medicaid fraud costs $70 billion to $200 billion each year, according to the National Health Care Anti-Fraud Association.
Anyone can commit fraud. That includes doctors, hospital employees, billing services, medical equipment suppliers, patients, and caregivers. Violators can be prosecuted under civil and criminal laws. And preventing fraud is everyone's job.
Santa Clara Family Health Plan (SCFHP) has established a comprehensive Fraud, Waste, and Abuse Program (FWA) to prevent, detect, and correct fraud, waste, and abuse by employees, members, employers, brokers, providers, contractors, and subcontractors of SCFHP. Under this program, SCFHP works to promote a sense of integrity and vigilance by means of comprehensive anti-fraud education for such individuals and entities. This program also provides procedures for prevention, detection, auditing, monitoring, investigation, and follow-up.
Frequently asked questions
If you suspect fraud, waste, or abuse, call the SCFHP 24/7 Fraud Hotline as soon as possible. All calls to the SCFHP Fraud Hotline are anonymous and confidential. You can also contact SCFHP by email, fax, or mail.
Mail: Compliance Officer
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158
Other ways to report Medicare or Medicaid fraud:
California Department of Health Care Services (DHCS)
Website: DHCS - Report Medi-Cal Fraud
Online form: Stop Medi-Cal Fraud On-Line Complaint Form
Mail: Medi-Cal Fraud Complaint – Intake Unit
Audits and Investigations
PO Box 997413, MS 2500
Sacramento, CA 95899-7413
Centers for Medicare & Medicaid Services
Mail: Medicare Beneficiary Contact Center
PO Box 39
Lawrence, KS 66044
HHS Office of Inspector General
Online form: File a Complaint Online
Mail: HHS Tips Hotline
PO Box 23489
Washington, DC 20026-3489
Healthcare fraud and abuse can take many forms. Examples of fraudulent activity by providers include:
- Billing for services that were not provided. This includes billing for no-shows.
- Billing for duplicate services or noncovered services as covered items.
- Billing for a more complex or expensive service than was provided (also called "upcoding").
- Misrepresenting a patient's diagnosis.
- Requiring a patient to return for unneeded follow-up services.
- Using an incorrect or inappropriate provider number to be paid.
- Signing blank records or certification forms that are used by another entity to obtain payment.
- Unbundling services from a group to increase medical payment.
- Misrepresenting dates, descriptions of services, or identities of patients or providers.
- Falsifying signatures or medical records.
- Accepting kickbacks or bribes for patient referrals.
Here are some steps you can take to protect your practice:
- Keep your provider number confidential. Be wary of anyone who requests your provider number without reasonable cause.
- Make copies of each patient's insurance card and driver's license.
- Maintain a treatment record for each patient and document all services, orders, and prescriptions.
- Carefully review all documentation before certifying the medical necessity of services or supplies needed/requested by patients.
- Have internal audits in place to detect billing inaccuracies promptly.
Contact SCFHP's Compliance Department if you discover:
- A patient using another person's healthcare ID card.
- A new patient asking for medication that is frequently abused.
- Any suspicious calls from medical equipment providers or others asking for your provider number.
Review Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians published by the Centers for Medicare & Medicaid Services.