Reporting Suspected Fraud and Abuse

Sutter Health Plan Anti-Fraud Program

You deserve to work with a health plan you can trust. By reducing the risk of fraud and abuse, we help lower costs for members, providers and the health plan. The Sutter Health Plan Anti-Fraud Program works to prevent, detect and address fraudulent activities. It also protects consumers by promptly identifying, investigating and resolving suspected fraud and abuse. These efforts comply with state and federal laws to ensure reliable and trusted healthcare services.

What Is Fraud and Abuse?

Healthcare fraud and abuse share similarities but have important differences.

Healthcare fraud: The intentional act of knowingly and intentionally submitting, or causing someone to submit, false or misleading information to obtain money or other healthcare benefits.

Healthcare abuse: Involves receiving payment for items or services without a legal right to it. However, it doesn’t require intent or awareness of wrongdoing.

Some examples of fraud and abuse include:

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

Reporting Suspected Fraud and Abuse

You can report suspected fraud and abuse to Sutter Health Plan using the following methods. You may remain anonymous regardless of the reporting method used.

*If you’re submitting your report by mail or email, please complete the Suspected Fraud and Abuse Reporting Form (PDF) or include the following information in your report:

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

Mailing Address

Sutter Health Plan
Attn: Ethics & Compliance Officer
P.O. Box 160307
Sacramento, CA 95816