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Report Fraud

Report Fraud

For Members - Why should you care about fraud and abuse?

Health care fraud and abuse are serious issues. Fraudulently received benefits or services impact the cost of your health care services. The cost of health care impacts the benefits available to you.

FRAUD is a dishonest act done on purpose. Examples of member fraud are:

  • Providing false information when applying for programs or services
  • Getting prescriptions with the intent of abusing or selling drugs
  • Letting someone else use your health care ID card

If you suspect fraud, you should report the situation to:

Compliance Officer
Santa Clara Family Health Plan
210 East Hacienda Avenue
Campbell, CA 95008

Or you may call our Compliance Hotline: 1-408-874-1450. This number is available 24 hours a day, 7 days a week.

You can also send a fax: 1-408-874-1970, or email us: ReportFraud@scfhp.com

Be sure to have as much information as possible. The more information you have, the better the chance the case will be successfully reviewed and resolved.
 

For Providers – SCFHP’s Fraud, Waste and Abuse Program

SCFHP has established a comprehensive Fraud, Waste, and Abuse Program 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.

Please notify SCFHP of potential fraud, waste or abuse. You can call our toll-free anonymous Compliance Hotline, email us, or send us a letter via fax or mail.

Compliance Officer
Santa Clara Family Health Plan
210 East Hacienda Avenue
Campbell, CA 95008

Or you may call our Compliance Hotline: 1-408-874-1450. This number is available 24 hours a day, 7 days a week.

You can also send a fax: 1-408-874-1970, or email us: ReportFraud@scfhp.com

 

What are fraud, waste and abuse?

Fraud is the intentional use of false statements to cheat another person or company out of something of value. It includes any act that constitutes fraud under state or federal law.
Waste is any unnecessary cost that results from poor or inefficient practices.

Abuse is an activity that goes against sound business, monetary or medical practices. Abuse may include practices by providers, members, or customers that result in unnecessary costs to the health plan.

Suspicious Activity is any activity that you think is fraudulent, wasteful, or abusive.

Some examples of suspicious activity by providers are:

  • Billing for services that were not provided. This includes billing for “no shows” (for example, billing members for services that were not actually furnished because the patients failed to keep their appointments).
  • Misrepresenting the diagnosis for the patient to justify the services or equipment furnished.
  • Requiring a member to return for unneeded follow-up services.
  • Balance billing members for services.
  • For additional information on fraud, waste and abuse, refer to SCFHP’s Provider Manual.