Preventing Healthcare Fraud, Waste, and Abuse
Healthcare fraud, waste, and abuse (FWA) is a serious issue that costs California billions of dollars each year. Beyond the financial impact, FWA can jeopardize the health, safety, and well-being of our members. Preventing fraud, waste, and abuse is a shared responsibility—one that involves both the Health Plan and our provider partners. Together, we can work to protect the integrity of the healthcare system.
San Francisco Health Plan maintains a robust Fraud, Waste, and Abuse Prevention Program in accordance with Title 42 of the Code of Federal Regulations (CFR), Section 438.608(a)(7), as required by our contract with the California Department of Health Care Services (DHCS). As part of this commitment, providers play a vital role and are required to stay up to date with current training to prevent, detect, and report any improper practices.
We appreciate your partnership in safeguarding the healthcare system for all members.
As a partner in fraud, waste, and abuse prevention, here are examples of fraud, waste, and abuse that you may encounter:
Fraud – Intentional deception or misrepresentation made to gain a benefit.
- Billing for services not rendered
- Altering medical records or claims to obtain payment
- Using another person’s insurance information to receive care
- Upcoding – billing for a more expensive service than what was actually provided
- Performing unnecessary procedures for financial gain
Waste – Overutilization of services or misuse of resources, not necessarily done with intent to deceive.
- Conducting excessive or duplicative testing
- Prescribing more medication than medically necessary
- Failing to coordinate care among providers, leading to redundant services
- Not following evidence-based clinical guidelines
Abuse – Practices that may result in unnecessary costs, often due to improper conduct or standards of care.
- Billing for services that are not medically necessary
- Charging excessively for services or supplies
- Misusing codes on a claim (e.g., using unlisted codes or misclassifying diagnoses)
Your role in prevention is critical. If you suspect FWA, report it to your organization’s compliance department or use the appropriate reporting channels. Together, we can protect our members and healthcare resources.
How to report Health Care Fraud, Waste and Abuse
If you have reason to believe that fraud, waste, or abuse (FWA) may have occurred, please contact us immediately. Your report could help protect the integrity of our healthcare system—and together, we can make a difference.
You can report suspected FWA through any of the following options:
- Phone: 1(800) 461-9330
- Email: [email protected]
Reports may be made anonymously, and all information will be handled confidentially to the extent allowed by law.
Thank you for your continued commitment to ethical and responsible healthcare practices.