Report Fraud, Waste and Abuse

California Health & Wellness takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste and abuse (FWA) program that complies with California and federal laws. In accordance with the California Code of Regulations (CCR), Title 22, Section 51460, Special Claims Review may be imposed on a provider upon a determination that the provider has submitted improper claims, including claims that incorrectly identify codes or services provided.

California Health & Wellness, in conjunction with its management company, Centene, successfully operates a fraud, waste and abuse unit known as the Special Investigation Unit (SIU). California Health & Wellness performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system; please review the Billing and Claims section of this manual.

The Special Investigation Unit (SIU) performs prospective and retrospective audits which, in some cases, may result in taking actions against those providers, individually or as a practice, who commit fraud, waste and/or abuse. These actions include but are not limited to:

  • Remedial education and/or training to prevent the billing irregularity
  • More stringent utilization review
  • Recoupment of previously paid monies
  • Termination of provider agreement or other contractual arrangement
  • Civil and/or criminal prosecution
  • Any other remedies available to rectify

Some of the most common FWA practices include:

  • Unbundling of codes
  • Up-coding services
  • Add-on codes billed without primary CPT
  • Diagnosis and/or procedure code not consistent with the member’s age/gender
  • Use of exclusion codes
  • Excessive use of units
  • Misuse of Benefits
  • Claims for services not rendered

If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call OIG’s Hotline at 1-800-HHS-TIPS (1-800-447-8477), directly to a Medi-Cal Fraud Control Unit (MFCU), or our anonymous and confidential FWA hotline at 1-866-685-8664. California Health & Wellness and Centene take all reports of potential fraud, waste or abuse very seriously and investigate all reported issues.  not sure what this means?

Please Note: Due to the evolving nature of wasteful, abusive and fraudulent billing, California Health & Wellness Centene may enhance the FWA program at any time. These enhancements may include but is not limited to creating, customizing or modifying claim edits, and upgrading software, modifying forensic analysis techniques, or adding new subcontractors to help in the detection of adherent billing patterns.

Authority and Responsibility

The California Health & Wellness Director of Compliance and Regulatory Affairs has overall responsibility and authority for carrying out the provisions of the compliance program. California Health & Wellness is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse.

The California Health & Wellness provider network will cooperate fully in making personnel and/or subcontractor personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials and in any other process, including investigations.