WebCom Page Main Content
Updated March 2026 Program integrity means taxpayer dollars are spent the right way: on care for people who need it. DHCS uses strong oversight, advanced data analytics, audits, fraud investigations, payment suspensions, cost recovery, provider terminations, and partnerships with law enforcement to prevent and address fraud, waste, and abuse and hold bad actors fully accountable. What does “fraud, waste, and abuse” mean in Medi-Cal?
Fraud, waste, and abuse happen when Medi-Cal funds are misused or taken through illegal actions. This can include billing for services that were never provided, coding that misrepresents the services provided, submitting false information, misrepresenting eligibility, or charging for medically unnecessary service/benefits. It may also involve schemes where someone offers money, gifts, or other incentives to individuals in exchange for applying for benefits, or to existing members for sharing their Medi-Cal identification information, which is ultimately used to submit false claims. These actions violate program rules and take resources away from people who truly need care. How does DHCS prevent, detect and address fraud?
- Provider Enrollment: Before providers can serve Medi-Cal members, DHCS conducts strict checks to prevent fraud by:
- Verifying required licenses and certifications
- Checking federal and state exclusion lists
- Reviewing ownership details to identify banned individuals
- Conducting site visits for higher-risk providers
- Performing fingerprinting and background checks when required
- Following federal guidelines in the Medicaid Provider Enrollment Compendium
- Prospective providers that fail to meet enrollment requirements are effectively prohibited from participating in the program thus preventing potential fraud from occurring had these providers been allowed to participate. DHCS also conducts monitoring of enrolled providers to ensure they continue to meet program requirements, and revalidates providers consistent with federal guidelines.
- Audits & Investigations: An interdisciplinary team of auditors, sworn investigators, clinicians, and data scientists in field offices throughout the state monitors providers and Medi-Cal claims to detect and stop misuse by:
- Using advanced data analytics to detect unusual billing patterns.
- Auditing and investigating high-risk providers. An objective of fraud prevention is to identify and stop fraud schemes as early as possible before they proliferate.
- Referring serious cases, based on a credible allegation of fraud, to the California Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse for criminal and civil prosecution.
- Partnering with health plans’ Special Investigation Units to share data, coordinate investigations, and strengthen fraud detection statewide. This collaboration makes fraud prevention a shared responsibility across DHCS and health plans.
- Third Party Liability and Recovery Division: DHCS ensures Medi-Cal pays only when no other party is responsible by:
- Recovering money from injury and accident cases, workers’ compensation claims, and estates.
- Using liens, offsets, and legal actions to reclaim improper payments.
- Deflecting costs to other health coverage when appropriate.
- Medi-Cal Eligibility: DHCS prevents misuse of funds by ensuring only eligible people receive Medi-Cal by:
- Checking income, residency, immigration status, disability status, and identity.
- Reviewing eligibility at application and renewal (every year, and every six months for some adults starting in 2027).
- Using electronic checks to confirm information and prevent duplicate enrollment in multiple states.
- Auditing counties every quarter to make sure eligibility rules are followed.
What happens when DHCS identifies fraud?
DHCS acts quickly to protect Medi-Cal and taxpayer dollars by: - Stopping payments to providers under investigation
- Suspending or removing fraudulent providers from the program
- Referring serious cases, based on a credible allegation of fraud, to the California Department of Justice for criminal or civil prosecution
- Recovering funds through legal actions
How can I protect my Medi-Cal Beneficiary Identification Card (BIC)?
- Never share your BIC with anyone except enrolled Medi-Cal providers or authorized representatives when receiving medical care.
- Avoid scams offering cash, gift cards, or other incentives for your Medi-Cal or personal information, especially if they are offering a service or treatment not requested or related in exchange for your information.
- Watch for warning signs such as unexpected bills or mail about benefits you didn’t use or apply for.
- If you suspect misuse, contact your local county office for a replacement card and report suspected fraud through DHCS’ contact options at Stop Medi-Cal Fraud .
I am a Medi-Cal provider. What should I do if I suspect my National Provider Identifier (NPI) is being misused?
Most Medi-Cal providers are committed to serving patients honestly and following program rules. If you believe your NPI is being used fraudulently, act immediately to protect your practice and Medi-Cal resources. Report suspected misuse to DHCS through the Stop Medi-Cal Fraud options. When reporting, include your NPI, any details of the misuse such as dates, claim numbers or payers involved, and any supporting documentation such as remits or screenshots. NPIs are publicly available, however providers should take all reasonable steps to ensure that their NPI is not being misused. Tips to prevent misuse of your NPI:
- Monitor your billing activity regularly for unusual claims or services you didn’t provide, or unknown billers/payers.
- Secure your credentials and limit access to authorized staff only.
- Train your team on fraud risks and reporting obligations.
- Keep licenses and certifications current and follow Medi-Cal program requirements.
- Be alert to scams and report early if you suspect misuse. Verify your profile information as listed on NPPES such as practice locations, taxonomy, contact information and update anything incorrect. You may also report suspected misuse directly through NPPES to flag the record.
- If your NPI has been misused, you may be able to obtain a new NPI, however you will need to complete all the necessary requirements through NPPES .
How can I report suspected fraud, waste, or abuse?
Anyone can report suspected fraud—including Medi-Cal members and Medi-Cal providers (doctors, dentists, behavioral health professionals, pharmacies, medical suppliers, and others). Reports can be anonymous. - 24/7 Hotline: (800) 822-6222
- متصل: https://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx
- بريد إلكتروني: fraud@dhcs.ca.gov
- البريد:
Medi-Cal Fraud Complaint – Intake Unit
Audits and Investigations
PO Box 997413, MS 2500
Sacramento, CA 95899-7413
