Health Care Fraud Prevention and Reporting

L.A. Care Health Plan does not tolerate health care fraud, waste and abuse. All questionable/suspect claims are thoroughly investigated, and cases are referred to the appropriate Federal and State authorities for prosecution.

If you suspect, experience or witness health care fraud, report the information to the L.A. Care Special Investigations Unit. Your reporting will be kept confidential.

Fraud, Waste and Abuse

What Is Health Care Fraud?

Health care fraud is a crime that occurs when someone intentionally and knowingly deceives for the purpose of illegal gain or getting an unauthorized benefit. Those involved in health care fraud steal billions of dollars each year from Federal and State governments, from  taxpayers, and from everyday people in communities all across the country.

Fraud drives up the costs for everyone in the health care system and threatens the sustainability of programs like Medicare and Medicaid, upon which millions of Americans depend. Some examples of health care fraud and abuse include:

Provider Fraud:

  • Billing for services not rendered
  • Double billing
  • Medically unnecessary services 
  • Accepting kickbacks for patient referrals
  • Misrepresenting dates and location of service
  • Misrepresenting provider of services
  • Waiving copays or deductibles
  • Prescribing medicines that are not medically necessary or for use by people other than the patient
  • Falsifying a patient’s diagnosis to justify tests, surgeries, etc.
     

Member Fraud:

  • Using someone else's insurance coverage for services
  • Identity theft
  • Forgery
  • Misrepresentation of medical condition
  • Failure to report third party liability (TPL)
  • Filing a claim for services or products not received
  • Obtaining medications or products that are not needed
  • Providing false information for coverage of product/service
  • Doctor shopping to get one or multiple prescriptions

Health care fraud affects costs for all of us. If you suspect, experience or witness health care fraud, report the information to the L.A. Care Special Investigations Unit.

Privacy and Security

How to Protect Yourself from Health Care Fraud

Although health care fraud is committed by a very small number of people within the health care system, no one can assume it won't happen to them. We encourage you to take these steps to avoid becoming a victim of health care fraud:

  • Beware of "free" medical services, as criminals use this as a lure to obtain your personal information.
  • Safeguard your member ID card.
  • Don’t give your member number to marketers or solicitors.
     

Privacy and Data Security

L.A. Care is strongly committed to protecting the privacy of your personal information. We have policies, procedures and systems in place that govern how we gather and use your protected health information. Such policies include:

How and Why We Get Your Personal Health Information 
After you become a member of our health plan, we get information about you from the program you join. We also get medical information from your doctors, clinics, labs and hospitals. This information helps us approve health care services you need, and pay for health care services you receive.

How We May Use and Share Information About You
We may use or share your information only if it is related to your health care program.

How We Protect Your Medical Information
We store your membership information and medical records in areas with limited access and in protected data systems. Limited personnel are allowed to access your information. We require these personnel to sign a Confidentiality and Protection Agreement, and train them extensively on privacy and security.

We also use security badges for area access, as well as passwords, firewalls and anti-virus software to protect your data. We constantly monitor our procedures, security systems and personnel to make sure your information is accessed appropriately and securely.

Avoid Identity Theft

Help Us Help You

If you suspect someone of inappropriately using your information or violating your privacy, call the L.A. Care Privacy Officer & Information Security Official at 1-888-839-9909. This number is available 24 hours a day, 7 days a week. Your call is free and confidential.

Protect Yourself from Identity Theft
Here are some steps you can take to help prevent your personal information from being stolen:

  • Protect your member ID card like you protect your bank or credit cards.
  • Take your ID card to your doctor’s appointment. Avoid saying out loud your membership information, personal info or social security number.
  • Don’t give out your personal information on the phone, through the mail or over the Internet unless you've initiated the contact or know who you're dealing with.