AUDITS & INVESTIGATIONS

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 Administration Support and Internal Audits:

• The Financial Audits Branch (FAB) ensures, through financial audits, that payments made to providers of Medi-Cal or other State or federally funded health care program 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.
• Local Educational Agency (LEA) is responsible for federally mandated audits of LEA providers.
• The 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.
• The 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.
• Provider-Preventable Conditions - Federal law requires that all providers report provider-preventable conditions (PPCs) that occur during treatment of Medi-Cal patients.  All PPCs associated with claims for Medi-Cal payment or with courses of treatment given to a Medi-Cal patient for which payment would otherwise be available. This link will provide additional information.
• The Specialty Mental Health Audits Section of the State Department of Health Care Services is responsible for conducting financial and compliance audits of cost reports submitted to the State by the County Mental Health Plans for reimbursement purposes.  These audits are conducted in accordance with Section 14170 of the Welfare and Institutions Code and include necessary procedures to determine compliance with applicable State and federal laws, regulations, and policies.
• The Administrative Support (AS) unit is responsbile for providing oversight and coordination to all A&I administrative functions.

REPORTS AND PUBLICATIONS

Federal Payment Error Rate Measurement

California is one of 17 States randomly selected by the Centers for Medicare and Medicaid Services (CMS) for the Payment Error Rate Measurement (PERM) initiative for Federal fiscal year (FFY) 2007 (October 1, 2006 - September 30, 2007). For FFY 2007, CMS will only measure Medicaid fee-for-service (FFS) claim payments and premium payments made on behalf of beneficiaries for accuracy.

Links related to the Federal Payment Error Rate Measurement

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