Preventing healthcare fraud

Healthcare fraud is increasing every year. Examples of health care fraud include billing for services not provided and using someone else’s identity (ID) to obtain benefits or receive payment. At Blue Shield of California Promise Health Plan, our goal is to work together with our network providers to prevent healthcare fraud.

Reporting fraud

If you suspect fraud or need guidance regarding fraud that could relate to claims or other business transactions impacting Blue Shield Promise, report it today to Blue Shield of California Special Investigations Unit:

 Phone: (800)221-2367, 9 a.m. to 5 p.m., Monday through Friday



Medicare fraud, waste, and abuse compliance program

Both Chapter 21 of the Medicare Managed Care Manual and Chapter 9 of the Prescription Drug Benefit Manual, collectively referred as the Compliance Program Guidelines and last revised on January 11, 2013, contain requirements mandating Medicare Advantage plans and standalone Part D plans to apply compliance training and communications, including fraud, waste and abuse (FWA) requirements, to first-tier, downstream, and related entities.

The Compliance Program Guidelines also instruct Medicare Managed Care plans and their contractors (first-tier), subcontractors (downstream), and other related business entities on how to implement the regulatory requirements under 42 Code of Federal Regulations (C.F.R.) §423.504(b)(4)(vi)(H), and how to implement a comprehensive FWA compliance plan to detect, correct, and prevent fraud, waste, and abuse.

Components of a comprehensive program to detect, prevent, and control Medicare Fraud, Waste, and Abuse are included as part of our General Compliance Plan Requirements.

Blue Shield Promise prohibits fraud, waste, and abuse and is committed to responding appropriately in the event that potential or suspected fraud, waste, or abuse is committed by its employees, vendors, subcontractors, contracted providers, or business associates.

The Compliance Program Guidelines provisions are integrated into each element of Blue Shield Promise’s existing Medicare Compliance Program. Blue Shield Promise’s FWA Program is organized to follow the core elements of a compliance plan in accordance with the Office of the Inspector General’s (OIG) Guidelines.


Fraud, waste and abuse component elements

The core elements involved in developing the fraud, waste, and abuse component of Blue Shield Promise's Medicare Compliance Program include:

  1. Written policies and procedures
    Blue Shield Promise has developed policies and procedures, including a Standard of Conduct, demonstrating its compliance and commitment as an entity that is contracted with the federal government.
  2. Compliance Officer and Compliance Committee
    Blue Shield Promise’s Vice President, Deputy General Counsel Chief Risk & Compliance Officer is Hope H. Scott, Esq..
  3. Training and education
    Blue Shield Promise provides computer-based-training (CBT) to its employees and temporary/contracted workforce members, so as to comply with regulations and assist in fraud, waste, and abuse prevention efforts. CBT training addresses pertinent laws related to fraud and abuse (e.g., Anti-Kickback Statute, False Claims Act, etc.) and includes a discussion of Medicare vulnerabilities identified by Centers for Medicare & Medicaid Services (CMS), the Office of the Inspector General (OIG), the Department of Justice, and other organizations as well as Blue Shield Promise. In addition, Blue Shield Promise provider communications also provide information to raise awareness of its fraud, waste, and abuse compliance requirements for its contracted and subcontracted entities.
  4. Effective lines of communication
    Blue Shield Promise has established a toll-free hotline to receive, monitor, process, and resolve non-compliant activities. Report any suspected or potential fraud, waste, or abuse to Blue Shield Promise via the following methods:
     Phone: (800) 221-2367 9 a.m. to 5 p.m., Monday through Friday
  5. Enforcement standards through well-publicized disciplinary guidelines
    Blue Shield Promise uses various avenues to encourage reporting of incidents of unethical or noncompliant behavior via annual mandatory general compliance training, newsletters, and department staff and committee meetings.
  6. Monitoring and auditing
    Blue Shield Promise develops an annual compliance and auditing program that protects the Medicare program and beneficiaries from Medicare fraud, waste, and abuse and may help mitigate Blue Shield Promise’s first-tier entities, downstream entities, and related entities' liability resulting from potentially fraudulent, abusive, or wasteful activities.
  7. Corrective action procedures
    Blue Shield Promise corrects and mitigates, within set timelines, noncompliant activities or violations committed and identified. Detailed Corrective Action Plans (CAPs) are used to describe the actions that will be taken, including a targeted timeframe, to correct and complete the identified non-compliance violation.


Report actual or suspected healthcare fraud online

If you suspect fraud, report it today.


Find the forms you need for authorizations, referrals, service requests, EFT enrollment, and provider disputes.

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