Compliance, fraud prevention, and privacy programs
Compliance program and code of conduct
Blue Shield of California Promise Health Plan commits to following all guidelines of the Department of Health Care Services (DHCS), Department of Managed Care (DMHC), and other related bodies. We always strive to act with integrity and honesty. We also comply with the law, our policies, and the Blue Shield Corporate Compliance and Ethics Program. We hold ourselves – and our partners and providers – to these standards.
Our standards include identifying and working quickly to fix non-compliance. When we do identify non-compliance, we act.
- DHCS Medical Audit CAP (PDF, 152 KB)
Healthcare fraud, waste, and abuse
We want you to understand what healthcare fraud is. Healthcare fraud costs the United States about $60 billion annually. That’s why we want you to know what fraud and abuse is. It’s also important for you to know how to report fraud. When you see something suspicious, report it.
What is fraud?
Fraud occurs when someone tries to get something of value by purposely lying, forging, or concealing. There are many types of fraud, and people commit fraud for various reasons. Fraud in the healthcare system is no exception.
Healthcare fraud may be an organized effort by a provider, member, or anyone else to cheat the system. It may also be the action of a lone provider who bends the rules to serve the perceived needs of a patient. These are two of many examples. Healthcare fraud is a serious and growing problem. It exploits patients and robs them of care critical to their well-being.
Examples of common types of healthcare fraud include:
- Provider fraud
- Billing for services not provided or “free services”
- Unbundling or up-coding (incorrect reporting to maximize payments)
- Waiving deductibles and/or copayments
- Falsifying dates or descriptions of services
- Billing non-covered services as covered items
- Subscriber/member fraud
- Loaning an ID card to someone else
- Changing amounts charged on claim forms or prescription receipts
- Filing false claims
- Non-subscriber or non-member fraud
- Using a stolen ID card to receive medical services
Our privacy commitment
At Blue Shield Promise, we understand the importance of keeping your personal information private. We take our obligation to do so very seriously.
In the normal course of doing business, we create records about you, your medical treatment, and the services we provide. Those records are protected health information (PHI). PHI usually includes your name, address, phone number, Social Security number, and health information. This may include healthcare diagnoses or claim information.
Federal and state law requires us to give you this notice of our legal duties and privacy practices about your PHI. We will maintain the privacy of your PHI and let you know if your PHI is breached.
Use this form to allow Blue Shield Promise to disclose your PHI:
Guarding your privacy
Find fraud prevention resources that teach you how to spot fraud, protect yourself, and take action. Learn more about medical identity theft:
Medical identity theft information (PDF, 744 KB)
List of resources (PDF, 34 KB)
Blue Shield Promise is committed to doing the right thing for our members. Our Delegation model (PDF, 133 KB) helps ensure the proper performance of our delegates. Data on our delegates can be found in our Delegation Reporting and Compliance Plan (PDF, 1.5 MB).
You can report compliance and privacy concerns in various ways. And you may do so anonymously. To submit a report:
Compliance and/or fraud
- Report online at Blueshieldcaexternal.ethicspoint.com
- Call (855) 296-9083, toll-free in the U.S. and Canada
- Email Promisestopfraud@blueshieldca.com
- Report online at bsc.i-sight.com/portal/reportonline.
- Call (855) 296-9086
- Email firstname.lastname@example.org
Frequently asked questions
See questions our members ask most frequently about Blue Shield Promise Medi-Cal.
Member rights and responsibilities
Find out about your rights and responsibilities as a Blue Shield Promise Medi-Cal member.
Download the Member Handbook for your area in your preferred language.
Language assistance services
Blue Shield of California Promise Health Plan complies with State and Federal civil rights laws and provides free language services to people whose primary language is not English. We communicate with our members in many different languages and dialects including English, Spanish, Cantonese, Mandarin, Armenian, Russian, Vietnamese, Khmer (Cambodian), among others.