Examples of Medi-Cal Fraud
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Most Medi-Cal providers are honest in their billing practices and provide quality health care to their patients. However, a relatively small number of providers commit fraud directly or become involved in fraudulent schemes. The following are examples of Medi-Cal provider fraud uncovered by CDHS investigators:
- A "capper" (an individual who recruits and pays patients for insurance fraud schemes) was paid to pick up Medi-Cal beneficiaries in vans and transport them to dental clinics. The dental services were billed to the Denti-Cal program, and people not licensed to practice dentistry performed some of the procedures.
- An individual who operated a laboratory and several medical clinics billed the Medi-Cal program for blood tests for "ghost" patients who were seemingly referred by a dozen physicians. When interviewed, all of the physicians denied ordering the tests.
- A person committed identity theft, i.e., used a Medi-Cal provider's identification to set up a fraudulent bank account and apply for new Medi-Cal provider numbers in the provider's name (without the provider's knowledge or authorization). The account was used to launder Medi-Cal warrants obtained using the new provider numbers.
A task force was established among A&I, the Medi-Cal Fraud Prevention Bureau, and Lab Field Services to conduct preliminary investigations of possible fraudulent activities as well as suspicion of harm to the Medi-Cal beneficiary.
The objective of this program is to maximize resources to quickly identify fraudulent providers and take appropriate administrative sanctions including suspending potential fraudulent practices expeditiously by placing Withholds and/or Temporary Suspensions on the provider. Since the initiation of the task force, five labs have been temporarily suspended from the Medi-Cal program and 27 labs have been closed.