Member Fraud Education
SFHP’s Health Care Fraud Awareness Program identifies, prevents, and fights fraud, waste, and abuse.
You Can Stop Fraud, Waste, and Abuse
Health care fraud, waste, and abuse cost billions of dollars each year. This has an impact on everyone who receives health care, including you. When money is lost due to fraud, waste, and abuse, it stops that money from being used to take care of other people.
You can help stop fraud by telling us about it.
What is Health Care Fraud?
Health care fraud includes making false or misleading statements on purpose to get payment, services, or money for health care services.
Tips for Preventing Health Care Fraud
- Do not allow others to use your ID card for any reason. Allowing someone to use your ID card can put your health at risk and can also be a criminal offense.
- Beware of “free” services. If you are asked to give your health insurance information for a “free” service or product, the service or product may lead to fraud.
- Keep your health insurance information safe. Treat it like a credit card. Do not share it or give it to others to use. Be careful when using it at the doctor’s office or pharmacy.
- Do not give your information to unknown callers. If you get a call from telemarketers offering free services or products, DO NOT give your medical ID number. They could use your information to get services and send false claims to your insurance company.
- Shred medical documents. This includes office notes, registration forms, and pharmacy labels once the information is no longer needed. Important medical information, like an ID card or Advance Directive, should be kept in a locked file.
- Check your prescriptions. Make sure you receive the medications your doctor ordered. Make sure you know what the doctor ordered by asking questions. You can look up a picture of the medication you were prescribed online.
Examples of Member Fraud:
- Giving information that is not true when signing up for programs or services.
- Getting prescriptions with the plan and abusing or selling them.
- Giving someone else your health care ID card to use.
Examples of Provider Fraud:
- If a provider gives a service that is not needed, just to bill extra for it.
- If a health care provider is billing for services you never received.
- If a provider bills for more costly services than they gave.
Examples of Pharmacy Fraud:
- If a pharmacy is giving medications without members calling in for refills.
- If a company is offering a drug plan that has not been approved by Medi-Cal.
- If a pharmacy is billing Medi-Cal for home medical equipment after it has been returned.
If you suspect health care fraud, waste, or abuse, tell us about it.
San Francisco Health Plan
Phone: 1(800) 461-9330 or 1(888) 883-7347 (TTY)
Email: Program_Integrity@sfhp.org
California Department of Health Care Services (DHCS)
Phone: 1(800) 822-6222
Email: stopmedicalfraud@dhcs.ca.gov