A&I - Investigations Branch

Audits & Investigations - Medi-Cal Beneficiary Fraud

Below is a list of the types of beneficiary fraud we investigate.

Early Fraud Detection Program (EFDP)

Applications for Medi-Cal benefits are reviewed at the county level prior to eligibility being established. County eligibility workers refer suspicious applications to DHCS/IB, whose investigators verify California residency, household composition and income/employment to ensure that applicants meet eligibility criteria.

Income Eligibility Verification System (IEVS)

Utilizing the Franchise Tax Board and Internal Revenue Service data, IEVS matches Medi-Cal beneficiary information with nationwide asset information and statewide employment data to determine if individuals are eligible to remain in the Medi-Cal program. IB submits it’s findings for criminal prosecution and/or recovery of monies expended when a beneficiary is discovered to be ineligible for services.

Failure to report other insurance coverage

Often, beneficiaries will not report other health insurance coverage due to a share of cost that other coverage requires.

Drug Utilization Enforcement (DUE)

Diversion of legal pharmaceuticals for illegal purposes is an escalating health and law enforcement issue. DHSC/IB utilizes computerized data analysis, surveillance, covert operations, informant management and interrogation of convicted/suspected beneficiaries to investigate Medi-Cal beneficiaries who seek multiple prescriptions from various physicians and hospital emergency rooms.

Social Security – Cooperative Disability Investigations

Through contractual arrangement between the Social Security Administration and DHCS/ IB, two (2) Investigators investigate suspicious disabled SSA recipients with linkage to Medi-Cal. Surveillance is generally conducted and beneficiaries are video taped performing tasks that are impossible according to their disability, i.e.; lifting heavy weights, cutting lawns, water skiing, walking, running, diving, etc. Often it is determined that the beneficiary and their physician have conspired to create the fictitious disability.

In Home Supportive Services

County departments of social services authorize certain Medi-Cal beneficiaries to receive services at home rather than placing an individual in long term care. Providers of these services can be friends and/or relatives. Some providers and/or beneficiaries engage in fraudulent behavior such as receiving payment for services not rendered; falsification of “time cards” with or without the permission of the recipient of the services, creation of multiple identities in order to receive payment for IHSS and receiving payment for providing services to dead individuals. In some instances, both the provider and beneficiary are involved in the fraudulent scheme.

Women, Infants and Children Program (WIC)

DHCS/IB investigates complaints involving WIC food vouchers which may result in high dollar losses to the program. Often, these investigations require covert surveillance involving multiple investigators and the use of undercover operatives.

Vital Statistics Investigations

IB investigators are notified by the California Department of Public Health, Vital Statistics, and various law enforcement agencies, county welfare departments, the Department of Motor Vehicles and county coroners, of possible fraudulent or altered vital statistics documents. Suspects who alter documents do so to avoid apprehension for criminal activities, to obtain aid and benefits which they are not entitled to or to stay in the country illegally.

"Common Sense Law Enforcement"