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Administrative Sanctions

Back to Stop Medi-Cal Fraud 

DHCS has the authority under the Welfare and Institutions Code to impose administrative sanctions on Medi-Cal providers. Some of the most common sanctions are withhold and temporary suspension.

The first of these sanctions involves withholding reimbursement for claims submitted. From July 2000 to February 2002, DHCS placed 582 providers on withhold.

When providers are placed on withhold, they may continue to bill the Medi-Cal program for services provided. The reimbursement they claim is withheld and placed in a special holding account, pending the outcome of further investigation of their Medi-Cal practices. As of February 2002, over $60 million is being held in the special holding account for these providers.

The second sanction involves temporarily suspending a provider from the Medi-Cal Program. From July 2001 to February 2002, CDHS has placed 617 providers on temporary suspension, which means they are suspended from the Medi-Cal program, and are therefore not entitled to reimbursement for any services provided to Medi-Cal beneficiaries.

"Withhold":
Upon receipt of reliable evidence of fraud or willful misrepresentation by a provider under the Medi-Cal program, the Department may withhold payment for any goods or services, or any portion thereof, from any Medi-Cal program provider. (Welfare and Institutions Code, Section 14107.11)

"Temporary Suspension":
If it is discovered that a provider is under investigation by the Department or any state, local, or federal government law enforcement agency for fraud and abuse, that provider shall be subject to temporary suspension from the Medi-Cal program, which shall include temporary deactivation of all provider numbers used by the provider to obtain reimbursement from the Medi-Cal program. (Welfare and Institutions Code, Section 14043.36)

Last modified on: 6/19/2014 9:54 AM