Compliance Information

Health Care Fraud

General Information

Understanding Your Role In Health Care Fraud

CalOptima Health 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 Health member or provider, please report it.

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

Compliance and Fraud, Waste and Abuse Reporting Form  If you see any activity that may be fraudulent, wasteful or non-compliant, we strongly encourage you to call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711). You can also report the activity using our Compliance and FWA Reporting Form. The confidential form has instructions on how to fill it out and where to send it. You do not have to give your name to report suspected fraud or abuse.

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

Medicare Fraud & Abuse: Prevent, Detect, Report  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.

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

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