Fraud, Waste and Abuse
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net takes the detection, investigation, and prosecution of fraud, waste and abuse (FWA) very seriously, and has a FWA program that complies with the State of California and federal laws.
Fraud means an intentional deception or misrepresentation made by persons with the knowledge that the deception could result in some unauthorized benefit to themselves or some other person, and includes any act that constitutes fraud under applicable federal or state law, including 42 CFR section 455.2 and W&I Code section 14043.1(i).
Waste is the overutilization or inappropriate utilization of services and misuse of resources.
Abuse means practices that are inconsistent with sound fiscal and business practices or medical standards, and result in an unnecessary cost to the Medi-Cal program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary cost to the Medi-Cal program.
Some of the most common FWA practices include:
- Unbundling of codes.
- Up-coding services.
- Excessive use or misrepresentation of quantity or units.
- Claims for services not rendered or failure to adequately document services.
- Services provided by non-credentialed providers without documentation indicating supervised services.
- Intentional misrepresentation of services rendered.
- Deliberate application for duplicate reimbursement.
- Intentional improper billing practices.
- Provision of unnecessary services.
- Failure to maintain adequate records to substantiate services.
- Failure to provide services that meet professionally recognized standards of health care.
- Conducting excessive office visits or writing excessive prescriptions.
Health Net, in conjunction with its parent company, Centene, operates a FWA Special Investigations Unit (SIU). Health Net routinely conducts audits to ensure compliance with billing regulations. Health Net has developed a proactive FWA prevention program designed to collect, analyze and evaluate data in order to identify suspected FWA. Detection tools have been developed to identify patterns of problematic healthcare service use, including overutilization, unbundling, upcoding, misuse of modifiers and other common schemes. SIU performs retrospective and prospective investigations which, in some cases, may result in taking actions against providers who commit waste, abuse, and/or fraud. Health Net is required to recoup all identified overpayments after review of claims and medical records.
These actions may include but are not limited to:
- Education.
- Corrective Action Plan.
- Utilization review.
- Prepayment review.
- Recoupment of identified overpayments.
- Termination of provider agreement or other contractual arrangement.
Referral of potential FWA to the California Department of Health Care Services, the California Department of Justice, and any other applicable agencies.
Providers and their office staff are legally required to report suspected cases of fraud and abuse to Health Net. Reports of suspected fraud may be made anonymously to the Health Net Fraud Hotline.