Reporting Suspected Fraud and Abuse

Sutter Health Plus Anti-fraud Program

Health care fraud costs the United States billions of dollars each year and affects everyone. The Sutter Health Plus anti-fraud program serves to prevent, detect and correct instances of fraud and abuse, thereby reducing costs to Sutter Health Plus, providers, members and others caused by fraudulent activities. The program is also designed to protect consumers in the delivery of health care services through the timely detection, investigation, and prosecution of suspected fraud and abuse in accordance with state and federal laws.

What is Fraud and Abuse?

Health care fraud is a criminal act of knowingly and intentionally submitting, or causing someone else to submit, false or misleading information to obtain money or any other health care benefit. Health care abuse is a similar activity or behavior that involves payment for items or services when there isn’t a legal right to that payment. However, abuse does not require that the person have intent or knowledge.

Some examples of fraud and abuse include:

• A provider billing for services or items that were not provided
• A provider falsifying medical records
• A provider paying a member to obtain care or services
• A member allowing someone else to use their health plan ID card
• Identity theft

Reporting Suspected Fraud and Abuse

You can report suspected fraud and abuse to Sutter Health Plus using any of the following methods.

Note: you may remain anonymous regardless of the reporting method used.

Anonymous Confidential Message Line: (800) 500-1950
Member Services: (855) 315-5800, TTY (855) 830-3500
Mail: Sutter Health Plus
Attn: Compliance Officer
P.O. Box 160307
Sacramento, CA 95816
Fax: (916) 736-5425 or (855) 759-5425
Email: shpcompliance@sutterhealth.org

If you are submitting your report by mail, fax, or email, please complete the Suspected Fraud and Abuse Reporting Form or include the following information in your report:

• When and where the suspected fraud occurred
• When and how the suspected fraud was discovered
• Description of the incident or suspected fraud
• Persons or entities engaged in the suspected fraud or who have attempted to conceal the issue