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Provider Overpayments (OP) Program

Provider Overpayments (OP) program is responsible for enforcing fiscal compliance with Medi-Cal laws and regulations for Medi-Cal providers and beneficiaries. The primary function is to recover funds due the Medi-Cal program, thereby reducing the total cost of the program.  Overpayment cases are referred by Audits and Investigations Division (A&I), other auditing and legal agencies, and Medi-Cal fiscal intermediaries (FI).

When a provider overpayment is identified, providers are sent notices of overpayments by the FI or demand-for-payment letters by the auditing organization.  These letters also notify the provider of their appeal rights. If the provider does not pay voluntarily, OP may take steps to have the FI offset the amount owed against current Medi-Cal claims payments, have the federal Centers for Medicare and Medicaid Services offset Medicare payments, seek a statutory judgment in Superior Court, and record liens against real and personal property that the provider owns.

Statutory Authority: California Welfare & Institutions Code, Sections 14172, 14172.5, 14173, 14176, 14177 (Not DHCS)

Regulations: California Code of Regulations, Title 22, Sections 51045, 51047 and 51458.1 (Not DHCS)

For beneficiary overpayments, the Department sends demand letters and makes phone calls seeking voluntary repayment. If these efforts are unsuccessful, OP may initiate offset of State Income Tax refunds and lottery winnings, pursue civil actions in Small Claims Court, or refer the case to the Attorney General’s Office to secure a judgment against the beneficiary’s assets and/or record a real property lien.

Statutory Authority: California Welfare & Institutions Code, Section 14009 (Not DHCS)

Regulations: California Code of Regulations, Title 22, Sections 50781-50791 (Not DHCS)

 

Any questions about OP should be directed to:

 

Department of Health Care Services
Third Party Liability & Recovery Division
Overpayments Section - MS 4720
P.O. Box 997425
Sacramento, CA  95889-7425


Telephone (916) 650-0575

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Last modified on: 9/25/2015 9:54 AM