Do You Suspect Fraud?

CenCal Health believes in continually improving the healthcare delivery system and part of this is through detecting, correcting and preventing fraud, waste and abuse. You can help stop fraud, waste and abuse by reporting your concerns to CenCal Health anytime you feel any of these may be occurring. 

If you suspect incidents of fraud, waste and/or abuse, you must report it to CenCal Health within 10 days from the date of when you first become aware or were put on notice of such activity. If you suspect another provider of fraudulent activity such as upcoding claims or performing unnecessary services, please report this information. Please also report any CenCal Health member you suspect is committing fraud.

Common Examples of Detected Issues:

  • Billing for services not rendered.
  • Billing for services at a frequency that indicates the provider is an outlier as compared with their peers.
  • Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered.
  • Billing for services that are actually performed by another provider.
  • Up-coding.
  • Modifier misuse.
  • Unbundling.
  • Billing for more units than rendered.
  • Lack of documentation in the records to support the services billed.
  • Services performed by an unlicensed provider but billed under a licensed providers name.
  • Alteration of records to get services covered.

Healthcare Fraud, Waste and Abuse are defined as:

Fraud

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (Title 42 CR 45502; Welfare and Institutions Code 1403.19(i))

Waste

Over utilization of services (not caused by criminally negligent actions) and the misuse of resources.

Abuse

Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care.

Fraud also includes recipient practices that result in unnecessary cost to the Medicaid program. (Title 42 CFR 455.2 and as further defined in Welfare and Institutions Code 14043.1(a)). 

REPORTING WILL ALWAYS REMAIN CONFIDENTIAL.

How To Report: 
  • Call our toll free 24-hour hotline at (866) 775-3944, or
  • Fill out a Fraud, Waste and Abuse Form

Fraud, Waste and Abuse (FWA) Forms:

Fraud by a Member
Fraud by a Provider

When Reporting Fraud, Waste or Abuse please provide as much of the following information as possible:

  • Name of person or persons suspected of committing fraud, waste or abuse. (First name, Last Name).
  • Identifying information such as: Provider/Member name, address or telephone number.
  • Description and Details of the suspected fraud waste or abuse: who, what, where, when, date and time of incident or incidents.
  • Any documentation you may have which is related to the situation.
  • Your name, telephone number (if you would like to be contacted), and address.
  • Please always note the program this issue is about: Medi-Cal or Healthy Kids.

Mail your completed FWA Form to the following address:

CenCal Health
Attn: Fraud Investigations-Compliance
4050 Calle Real
Santa Barbara, CA 93110