Preventing Fraud, Waste and Abuse

The purpose of Scripps Health Plan Service’s anti-fraud plan is to establish methods for objectively and systematically evaluating and investigating potential fraud, waste, and/or abuse of Scripps Health Plan Services delivery system.

Scripps Health Plan Services strives to continuously improve the structure, processes, and outcomes of its anti-fraud activities.

What is fraud

Health care fraud is the intentional misrepresentation for financial gain by an individual, group or entity. Fraud occurs when an individual or entity knows (or should know) that something is false and takes deceptive actions with the intent to receive an unauthorized benefit to themselves or another person.

What is abuse

Abuse includes actions that may result in unnecessary costs; improper payment; payment for services that fail to meet professionally recognized standards of care; or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented the facts to obtain payment.

Abuse cannot be differentiated categorically from fraud because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.

What is waste

Waste within health care means over-utilization (using more than needed) of health care services, or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Fraud, waste, and abuse within health care is costly for everyone. It leads to higher health care costs and premiums, more uninsured people, and fewer dollars available for necessary health care services.

Health care fraud, waste and abuse comes in many forms and requires providers, members, and Scripps Health Plan Services to work together to prevent unnecessary costs. We work closely with our affiliates and are committed to effectively reducing fraudulent activity. The most prevalent examples of misspending that occur in health care today include:

  • Falsification of drug prescriptions
  • Fabrication and/or falsification of a claim or supporting documentation which impacts the rate of reimbursement, capitation, or other payment
  • Unbundling of claims for which established payment guidelines those services should be billed as a “bundle” (one payment for multiple services)
  • “Up-coding” or “down-coding” of claims or otherwise making a false representation of the clinical severity, complication or other factor impacting the rate of reimbursement
  • Use of benefits by non-covered persons (with or without the knowledge of the beneficiary), e.g., use of health plan ID cards by persons who are not entitled to benefits
  • Excessive charges for services or supplies above the usual, customary, and reasonable charges for those items or services or contrary to an agreed upon contracted rate
  • Charges for services which are included in the capitation rate
  • Soliciting, offering, or receiving a kickback, bribe, or other self-benefit, in violation of the Stark Law and anti-kickback regulations (e.g., paying for patient referrals or member assignments)
  • Fraud or abuse perpetrated by plan staff and/or contracted network staff for purposes of self-benefit or to improperly compensate or receive compensation from a network provider

If you suspect fraud, waste, or abuse, please notify us immediately:

  • Scripps Health Plan Services Chief Compliance Officer - 858-927-5360
  • Compliance and Patient Alert Line (confidential and toll-free) - 888-424-2387

You are protected

Scripps Health Plan Services believes no person should be retaliated against for reporting a concern about potential misconduct. Reporters who wish to be kept anonymous shall be, to the extent practical and permissible by law. Scripps Health Plan Services does not tolerate threats or actions of retaliation, retribution or other negative acts that would dissuade an individual from reporting potential misconduct. Furthermore, federal “whistleblower” protections shield reporters from retaliation for making a report of potential misconduct in good faith.