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You Can Make a Difference – Report Suspected Fraud

Did You Know?


  • Health care fraud is contributing to the rising cost of health insurance.
  • Health care fraud reduces the amount of funds available to pay honest providers.
  • Health care fraud increases premiums to employers and members.
  • Health Net will investigate allegations of fraud, waste and abuse – and reports of non-compliance on any level.
  • Health Net's Special Investigations Unit is available as a resource to Health Net employees, members and providers, as well as to Health Net's delegates – first tier, downstream, and related entities.
  • See below for examples of fraud and more.

How to Report

Health Net's Fraud hotline and Integrity hotline are available 24/7, and callers may choose to remain anonymous.

  • Health Net Fraud Hotline: 1-800-977-3565
  • Health Net Integrity Hotline: 1-888-866-1366

What to include in your report:

  1. Unless you choose to remain anonymous, please provide your name, telephone number, address, and email address. If you are submitting your report anonymously, please take care to withhold personally identifiable information.
  2. Explain the nature, scope and time frame of the activity in question.
  3. Explain how you are aware of the alleged activity.
  4. Specify if you know of any potential witnesses to the activity.
  5. Provide any documents or other physical evidence in your possession.
  6. For more information, please reference Health Net's Code of Conduct (pdf).

Fraud Awareness Tips

The following links explain common fraud schemes that could impact members.

The following link addresses the appropriate method of disposing of prescription drugs and why this issue is so important.


Examples of Fraud and Non-Compliance

Some examples of consumer health care fraud: Some examples of
provider health care fraud:
  • filing claims for services or medications not received
  • forging or altering bills or receipts
  • using someone else's coverage or insurance card
  • billing for services not actually performed
  • falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
  • upcoding – billing for a more costly service than the one actually performed
Some examples of non-compliance:
  • theft or unauthorized removal of company/business documents from the premises
  • falsifying or tampering with company documents or records
  • violations of Health Net's Code of Conduct
  • insubordination, dishonesty, gross carelessness/negligence of duties
Five counties with high incidences of fraud, waste and abuse:*
Broward County, Florida | Harris County, Texas | Kings County, New York
Los Angeles County, California | Miami-Dade County, Florida.

*As of July 1, 2011, The Centers for Medicare & Medicaid Services identified these five counties as most at risk for high incidences of fraud, waste and abuse.

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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