Audits & Investigations

Mission

The mission of Audits and Investigations (A&I) is to ensure the fiscal integrity of the health programs administered by the Department of Health Care Services (DHCS) and ensure quality of care provided to the beneficiaries of these programs. The overall goal of A&I is to improve the efficiency, economy, and the effectiveness of DHCS and the programs it administers. To carry out its mission A&I will:

• Perform special audits as needed by DHCS program managers, executive staff, California Health and Human Services Agency (CHHS), or the Governor's Office.
• Perform internal audits of DHCS organizations to ensure that various internal controls are operating and effective.
• Perform medical reviews of Medi-Cal and public health providers.
• Provide technical assistance (financial and medical) in the development and expansion of the Managed Care program.
• Identify and investigate Medi-Cal beneficiary and provider fraud and abuse, emphasizing fraud prevention.
• Participate in the development or modification of DHCS policies.

A&I is divided with three branches along with Internal Audits.  In addition, the division includes the Administrative Management Services Section (AMSS) and Information Technology Unit (ITU) which provides centralized administrative functions and technology services to A&I, respectively.

• Financial Audits Branch (FAB) ensures, through financial audits, that payments made to providers of Medi-Cal or other State or federally funded health care programs are valid, reasonable, and in accordance with laws, regulations, and program intent.
•  Audits performed by FAB are now available on-line and can be located under the Data & Statistics section of the DHCS website.

• Investigations Branch (IB) is mandated by the Code of Federal Regulations and California State law as the organization responsible for investigating allegations of beneficiary fraud and abuse of the Medi-Cal program. 

• Medical Review Branch (MRB) is charged with the responsibility of performing federal mandated post service, post payment utilization reviews. 

• Internal Audits (IA) is an independent organization housed within A&I that is charged with department-wide program audit responsibilities.

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