Stopping fraud

How can you help us fight health care fraud? 

Health care fraud is an intentional deception or misrepresentation that an individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual, the entity or some other party. Recent estimates put the impact of health care fraud in the United States at approximately $60 billion per year. Health care fraud is costly for everyone. It leads to higher premiums, more uninsured people and fewer dollars available for health care services.

Health care fraud comes in many forms, including:

• Submitting fraudulent claims (e.g., billing for services that were not provided or inappropriately coding claims to result in higher charges)
• Use of health plan ID cards by people who are not entitled to benefits
• Falsification of drug prescriptions
• Offering free diabetic supplies, medical supplies or genetic tests in exchange for your ID number or other personal information
• Enrolling someone on your plan who is not an authorized family member or keeping someone on your plan after they are no longer eligible (e.g., after a divorce)

Sharp Health Plan is committed to working to reduce fraudulent activity. Here are some things you can do to prevent fraud:

• Do not give your Sharp Health Plan identification (ID) number over the phone or to people you do not know, except for your health care providers or Sharp Health Plan representatives.
• Do not enroll individuals who are not eligible for coverage as your spouse or dependent.  (Individuals can enroll in their own plan at sharphealthplan.com or coveredca.com.)
• Let only the appropriate medical professionals review your medical record or recommend services.
• Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill to get it paid.
• Carefully review explanations of benefits (EOBs) statements that you receive from us to ensure we have not been billed for services you did not receive.
• Do not ask your doctor to make false entries on certificates, bills, or records in order to get an item or service paid for.
• If you suspect a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, call the provider and ask for an explanation. There may be an error.

If you suspect fraud, abuse or waste

What if you suspect fraud? Contact Sharp Health Plan Customer Care at 1-800-359-2002 or customer.service@sharp.com.

Or send a letter to:

Sharp Health Plan
Fraud and Abuse Investigations
8520 Tech Way Suite 200
San Diego, CA 92123

You do not have to give your name. Just tell us why you think fraud is occurring. Give us the name of the provider or member, and tell us what you are concerned about. We take your questions and input seriously. You can help us stop health care fraud.

If you suspect non-compliance or fraud related to Medicare, you can also contact us anonymously using the Sharp HealthCare dedicated hotline number at 1-800-350-5022.