Reporting Fraud, Waste and Abuse
California Health & Wellness is serious about finding and reporting times that California Medicaid funds are used in the wrong way. This is called waste, fraud or abuse.
"Fraud" means to knowingly get benefits or payments that you are not entitled to receive. Please let us know if you are aware of someone who is committing fraud. This could be a provider or a member. Some examples of healthcare fraud include:
- A lie on an application
- Using someone else's ID card
- A provider (doctor) billing for services that were not done
- Transportation (usage abuse)
Waste is the overuse of services that may result in costs not needed for health care benefits. This includes direct costs and indirect costs. Waste usually results from the misuse of services.
Abuse means causing any physical, sexual or mental injury to you. This can also be taking advantage of your financial resources.
- Physical abuse. Any inappropriate contact that causes bodily harm. For example, being slapped, scratched, or pushed. Being threatened with a weapon, such as a knife or a gun, is another example.
- Sexual abuse. Any sexual behavior or intimate physical contact that occurs without your permission. This can be touching your genital area, buttocks or breasts.
- Mental abuse. When you feel emotional distress resulting from the use of demeaning or threatening words. This can also include signs, gestures and other actions. For example, controlling behavior, embarrassment or social isolation are types of mental abuse.
- Financial Abuse. When someone uses your money without your consent. This includes improper use of guardianship or power of attorney.
You trust that your doctor, caregiver or loved one will take care of you. You believe they will always have your best interests in mind. Sometimes, when someone helps take care of you, they can take advantage of you. It is important to recognize the signs of neglect, abuse and fraud. If this happens, it is important to report it. This allows you to be safe and get the care you need.
California Health & Wellness is serious about finding and reporting fraud and abuse. Our staff is available to talk to you about this. Here is the address and phone numbers:
California Health & Wellness
4201 E Commerce Way
Sacramento, CA 95834
1-877-658-0305 (TTY: 711)
Or you can call the California Health & Wellness Fraud, Waste and Abuse Hotline at 1-866-685-8664.
You can also report fraud and abuse to the Bureau of Medi-Cal Fraud. The address and number are:
Office of the Attorney General
Bureau of Medi-Cal Fraud Unit
P.O. Box 944255
Sacramento, CA 94244-2550
Your healthcare benefits are given to you based on your eligibility for both Medi-Cal and the California Medi-Cal Managed Care Program. Sharing your Medi-Cal benefits is not allowed. California Health & Wellness network providers are required to report any misuse of benefits to California Health & Wellness. California Health & Wellness is required to report any misuse or wrongful use of benefits to Medi-Cal. If you misuse your benefits, you could lose them. Medi-Cal may also take legal action against you if you misuse your benefits.
If you think a doctor, hospital, another California Health & Wellness Member or another person is misusing the Medi-Cal or California Health & Wellness resources, tell us right away. Will look into any misuse of resources. California Health & Wellness will take your call about waste, abuse and fraud seriously. Call the California Health & Wellness Waste, Fraud and Abuse Hotline at 1-866-685-8664. You do not need to give your name.
If you receive a bill for services that you did not receive this could be fraud. Please call Member Services at 1-877-658-0305 (For TTY, contact California Relay by dialing 711 and provide the 1-877-658-0305 number).To report waste, abuse, or fraud, gather as much information as possible.
To report waste, abuse, or fraud, provide as much information as possible. This will make it easier to investigate.
When reporting about a provider (a doctor, dentist, counselor, etc.) it's helpful to, but not required, to include all of the following:
- Name, address, and phone number of provider
- Name and address of the facility (hospital, nursing home, home health agency, etc.)
- Medi-Cal number of the provider and facility, if you have it
- Type of provider (doctor, dentist, therapist, pharmacist, etc.)
- Names and phone numbers of other witnesses who can help in the investigation
- Dates of events
- Summary of what happened
When reporting about someone who gets benefits, include:
- The person's name
- The person's date of birth, or case number if you have it
- The city where the person lives
- Specific details about the waste, abuse, or fraud