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Health Care Fraud

CalOptima Health is committed to upholding the highest business and professional standards to prevent health care fraud, waste and abuse. We comply with all applicable state and federal laws, regulations and contracts to protect our members and providers in Orange County.

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Protect Your Personal Information

The Federal Bureau of Investigation (FBI) and Centers for Medicare and Medicaid Services (CMS) have seen a rise in emails, texts, faxes and phone calls where scammers pretend to be from trusted organizations to steal sensitive information (also known as “phishing” or “smishing”). These scams can lead to identity theft, fraud and disrupted care.

To protect yourself:

Save CalOptima Health’s number, 225678 (CALOPT), to your phone contacts, so you recognize messages that really come from us
Watch out for unexpected emails, texts, faxes and phone calls asking for sensitive information
Always check who is asking for your information
Never share your CalOptima Health ID, Social Security number or other personal details
Regularly review your Explanation of Benefits (EOB) and notices of claims for any services you don’t recognize or didn’t get
If you suspect fraud or mistakenly shared your information, call CalOptima Health at 1-888-587-8088 (TTY 711) right away. For your safety, you can also request a security passcode for your account

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What Is Health Care Fraud and Abuse?

Fraud and abuse can take many forms. Below are common examples:

Upcoding: Billing for a more expensive service than provided
Services Not Rendered: Charging for services that were never given
Excessive Units and Visits: Billing for more services than medically necessary
Billing Under Another Provider’s ID: Using someone else’s ID number or National Provider Identifier
Incorrect Coding: Using the wrong billing codes or combining codes improperly
Unbundling: Separating services that should be billed together
Unauthorized Providers: Billing for care provided by non-licensed providers
Double Billing: Charging twice for the same service
Misrepresenting Level of Care: Claiming a higher level of care than provided
Patient Overload: Billing for an excessive number of patients in one day
Misusing Modifiers: Applying billing modifiers incorrectly
Lack of Documentation: Failing to document medical necessity
Over/Underutilization: Providing too much or too little care
Billing for No-Shows: Charging for canceled or missed appointments
Falsifying Records: Altering clinical notes or documents
Forgery: Faking signatures or records

How to Report Health Care Fraud and Abuse

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). Not sure if it’s fraud or abuse? Let us know below. Reports can be made anonymously — no detail is too small to review.

Compliance and Fraud, Waste and Abuse Reporting Form
This 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 and 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.