Health Care Fraud

Understanding Your Role in Health Care Fraud

Estimates indicate that more than $60 billion in health care fraud occurs each year, or about 3 percent of health care expenditures.

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

Health care fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themselves or others.

Health care program abuse is when a provider's practices are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to the Medi-Cal program.

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. CalOptima then determines if there is a likelihood of fraud or abuse, and refers such cases to the California Department of Health Care Services and/or CMS’s MEDIC.

We appreciate your support and partnership while we keep the CalOptima system one of the utmost integrity and one free of fraud and abuse.

Thank you!

CalOptima’s Compliance Officer

Report Fraud and Abuse

Hotline: 877-837-4417

Fax: 714-481-6457




Special Investigations Unit

Office of Compliance

505 City Parkway West

Orange, CA 92868

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