Skip Ribbon Commands
Skip to main content

Medi-Cal Fraud And Abuse - Audits & Invetigations

 

CONTACT US

1.800.822.6222

 stopmedicalfraud@dhcs.ca.gov

 

 

Do You Suspect Medi-Cal Fraud?

The Department of Health Care Services (DHCS) asks that anyone suspecting Medi-Cal fraud, waste, or abuse  to call the DHCS Medi-Cal Fraud Hotline: 1-800-822-6222.  Our recorded message may be heard in English and four other languages: Spanish, Vietnamese, Cambodian, and Russian. The call is free and the caller may remain anonymous.

Report Medi-Cal Fraud Electronically

You can e-mail us at stopmedicalfraud@dhcs.ca.gov or complete the Online Complaint Form.

 

What Is Fraud?

Medi-Cal fraud is theft of government money. Healthcare fraud, waste, and abuse can involve physicians, pharmacists, beneficiaries, and even medical equipment companies. Medi-Cal fraud is an intentional attempt to receive unauthorized payments or benefits from the Medi-Cal program. Fraud can take many forms, some examples of Provider and Beneficiary fraud include:

BENEFICIARY FRAUD

  • Intentionally under reporting income, assets, resources etc.
  • Residing out-of-state.                                                      
  • Drug seeking behaviors.                                            
  • Provider billing irregularities.
  • Excessive charges for services or supplies.
  • Billing for services not provided
  • Using stolen Medi-Cal cards and numbers
  • Filing claims for services or items not furnished
  • Selling supplies/equipment/medications
  • Providing false information

 

PROVIDER FRAUD

  • Drug Medi-Cal
  • Provider Billing Beneficiary
  • Poor Quality of Care
  • Capping

 

Medi-Cal Provider Fraud affects everyone. Providers include doctors, dentists, hospitals, pharmacies, clinics and any other individual or company that is paid by Medi-Cal. Although most providers are honest and dedicated to providing quality care to their patients, dishonest medical providers steal millions of dollars each year through fraudulent or abusive practices.  Reporting fraud helps our Unit return this money to the system so it can provide a healthcare safety-net to those most in need.

 

What Is Not Fraud?  

The following examples are not necessarily fraud issues

·       Lost or stolen Medi-Cal Beneficiary Identification Cards (BIC):  If you have just lost your BIC card, contact your county worker for a replacement. Fraud occurs if there is knowledge that a stolen or lost card has been or is currently being used fraudulently.

·       Pregnancy/ pre-natal care for foreigners: residing or coming for the express purpose to deliver in California is not necessarily fraud.

·       Dual Coverage: dual coverage for children (both private insurance and Medi-Cal) is allowed with prior knowledge.

·       Transferring of assets:  Transferring of assets is not necessarily fraud and is allowed to an extent.

·       IHSS check splitting: an IHSS provider and recipient may split/share the provider’s check only if all the services have been provided.

Stop Medi-Cal Fraud & Abuse Logo

How Do We Stop Fraud

DHCS has made significant strides toward detecting and preventing Medi-Cal fraud. Staff in Audits and Investigations are using new auditing and investigative procedures to monitor the practices and billing activity of providers. They work to assure quality care is provided, reduce the occurrence of fraud, uncover instances of provider and beneficiary identity theft and make referrals for criminal investigation and prosecution. 

Provider enrollment procedures used by the Provider Enrollment Division to help prevent fraud include:

  • more extensive application packages
  • provider background checks
  • onsite reviews
  • Suspension (moratoriums) on enrollment of new adult day health care centers, clinical laboratories and durable medical equipment providers located outside of California and in Los Angeles, Orange, Riverside and San Bernardino Counties
  • As well as, non-chain, non-pharmacist owned pharmacies in Los Angeles County.

 

» Audits & Investigations 

» Examples of Medi-Cal Fraud 

» Administrative Sanctions 

» Criminal Convictions 

» Stop Medi-Cal Fraud Campaign

» Report IHSS Fraud

 

 

 

 

 

 

 

 

 

 

 

Last modified on: 8/25/2015 1:47 PM