Section 1348 Of Article 2. Administration From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 2.
1348
. (a) Every health care service plan licensed to do business in
this state shall establish an antifraud plan. The purpose of the
antifraud plan shall be to organize and implement an antifraud
strategy to identify and reduce costs to the plans, providers,
subscribers, enrollees, and others caused by fraudulent activities,
and to protect consumers in the delivery of health care services
through the timely detection, investigation, and prosecution of
suspected fraud. The antifraud plan elements shall include, but not
be limited to, all of the following: the designation of, or a
contract with, individuals with specific investigative expertise in
the management of fraud investigations; training of plan personnel
and contractors concerning the detection of health care fraud; the
plan's procedure for managing incidents of suspected fraud; and the
internal procedure for referring suspected fraud to the appropriate
government agency.
(b) Every plan shall submit its antifraud plan to the department
no later than July 1, 1999. Any changes shall be filed with the
department pursuant to Section 1352. The submission shall describe
the manner in which the plan is complying with subdivision (a), and
the name and telephone number of the contact person to whom inquiries
concerning the antifraud plan may be directed.
(c) Every health care service plan that establishes an antifraud
plan pursuant to subdivision (a) shall provide to the director an
annual written report describing the plan's efforts to deter, detect,
and investigate fraud, and to report cases of fraud to a law
enforcement agency. For those cases that are reported to law
enforcement agencies by the plan, this report shall include the
number of cases prosecuted to the extent known by the plan. This
report may also include recommendations by the plan to improve
efforts to combat health care fraud.
(d) Nothing in this section shall be construed to limit the
director's authority to implement this section in accordance with
Section 1344.
(e) For purposes of this section, "fraud" includes, but is not
limited to, knowingly making or causing to be made any false or
fraudulent claim for payment of a health care benefit.
(f) Nothing in this section shall be construed to limit any civil,
criminal, or administrative liability under any other provision of
law.