¿Qué es el fraude? 
Volver para Detener el Fraude de Medi-Cal
Protect Medi-Cal. Protect Care.
Medi-Cal is a lifeline for millions of Californians. Every dollar lost to fraud, waste, or abuse is a dollar that cannot be used for health care. DHCS works with members, providers, and partners to prevent, detect, and stop fraud, and you can help.
You can help: Make sure you know the types of fraud and report fraud or call (800) 822-6222 if you suspect something.
Miembros de Medi-Cal
Most Medi-Cal members follow the rules and receive the health care they need. Fraud occurs when individuals misrepresent information or engage in dishonest practices to obtain benefits they are not entitled to. Examples include:
- Exceeding income or asset limits: Failing to report income or assets to qualify for Medi-Cal.
- Identity theft: Using another person’s personal information to obtain benefits.
- False information: Providing inaccurate details about residency or household composition.
Proveedores
Most providers follow the rules and deliver quality health care to their patients. Fraud occurs when providers misrepresent information or engage in dishonest practices to obtain payments they are not entitled to, or when providers are targeted by individuals seeking to exploit the program. Examples include:
- Billing for services not rendered: Charging Medi-Cal for care that was never provided.
- Unnecessary services: Ordering tests or procedures that are not medically necessary.
- Phantom billing: Submitting claims for equipment or supplies never delivered.
- Kickbacks and capping: Paying or offering gifts to recruit patients into Medi-Cal, or being pressured by third parties to participate in such schemes.
- Balance billing: Charging members for amounts beyond Medi-Cal’s reimbursement rate.
In-Home Supportive Services
The In-Home Supportive Services program helps people live safely at home. Fraud occurs when members or providers misrepresent information or engage in dishonest practices, or when either party is drawn into fraudulent schemes. Examples include:
- Miembros:
- Claiming services they do not need.
- Demanding part of the provider’s paycheck.
- Proveedores:
- Billing for services not performed (e.g., while the member is hospitalized or out of the country).
- Forging timesheets or colluding with members to split payments.
- Being pressured or misled into fraudulent billing practices by third parties.
Fraud, waste, and abuse threaten the integrity of Medi-Cal and take resources away from those who need care. DHCS is committed to accountability and transparency, but we can’t do it alone. Protecting Medi-Cal is a shared responsibility, and you play a critical role. If you suspect Medi-Cal fraud,
report it immediately.
