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Stopping healthcare fraud, waste, and abuse (FWA)

Provider news | Tuesday, November 10, 2020

Healthcare fraud is a serious issue that contributes to the skyrocketing cost of medical care. The National Health Care Anti-Fraud Association estimates that Medicare and Medicaid fraud costs $70 billion to $200 billion each year.
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. Preventing fraud is everyone's job.
Healthcare fraud, waste, 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 non-covered 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:

  • 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.

If you suspect fraud, waste, or abuse, contact SCFHP as soon as possible. All calls to the SCFHP Fraud Hotline are anonymous and confidential.
Call: SCFHP 24/7 Fraud Hotline:1-408-874-1450 (TTY:711)
Attn: Compliance Officer
Santa Clara Family Health Plan
PO Box 18880

San Jose, CA 95158

Learn more about FWA and how and when to report Medicare and Medicaid fraud.