Compliance Information

Health Care Fraud

General Information

Understanding Your Role In Health Care Fraud

CalOptima embraces and adheres to business and professional practice standards consistent with applicable state and federal law, regulatory, and contractual requirements to eliminate health care fraud, waste and abuse within our network across Orange County.

Examples Of Health Care Fraud And Abuse Include:

  • Upcoding
  • Services not rendered
  • Excessive units and visits
  • Billing under another provider’s ID # or TIN/NPI
  • Billing HCPCS units with CPT codes
  • Unbundling
  • Non-licensed professionals providing services
  • Double billing
  • Level of care misrepresentation
  • Billing for excessive numbers of patients in one day
  • Misuse of modifiers
  • Lack of medical necessity documented
  • Over- or underutilization
  • Billing for cancellations or no-shows
  • Falsifying clinical notes
  • Forgery

If you are aware of suspected fraud or abuse involving a CalOptima member or provider, please report it.

If you are unsure about whether something is fraud or abuse, please refer it to CalOptima’s Special Investigation Unit for investigation. You can report suspected or potential fraud or abuse anonymously.

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Medicare Learning Network FWA Training Use the Medicare Learning Network® web-based training online here.

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Medicare Fraud & Abuse: Prevent, Detect, Report Download PDF Icon View the Medicare Learning Network publication on fraud and abuse definitions, laws, how to report suspected fraud, and physician business relationships that may raise concerns.

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Report Fraud or Abuse Download PDF Icon If you see any activity that you think is fraudulent or wasteful, we strongly encourage you to call our Compliance and Ethics Hotline at 1-877-837-4417 or report the activity using the Suspected Fraud or Abuse Referral Form. You do not have to give your name to report fraud activity.

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CMS Fraud Handbook Download PDF Icon Learn about detecting and preventing fraud in Medicare Part C and D here.

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