Tsev Cov tib neeg Kev Tshuaj Xyuas thiab Kev Tshawb Fawb​​ 

ua Kev Tshawb Fawb thiab Kev Tshawb Fawb​​ 

Kawm txog Kev Ncaj Ncees ntawm Qhov Kev Pab Cuam​​ 

Lub hom phiaj​​ 

Kev Tshawb Fawb thiab Kev Tshawb Fawb (A&I) yog Lub Tsev Haujlwm Saib Xyuas Kev Ncaj Ncees rau California's Medicaid program – Medi-Cal. A&I lub luag haujlwm yog los tiv thaiv thiab txhim kho kev ncaj ncees ntawm cov kev pabcuam kev noj qab haus huv uas tswj hwm los ntawm DHCS. Txhawm rau ua qhov no, A&I ua kev tshawb xyuas nyiaj txiag thiab kev ua raws cai, suav nrog kev tshuaj xyuas kev siv nyiaj tom qab them nyiaj tom qab kev tshuaj xyuas ntawm Medi-Cal cov kws kho mob; ua raws li txoj cai thiab kev kuaj mob ntawm kev kho mob, kho hniav thiab tus cwj pwm kev noj qab haus huv tswj kev npaj; txheeb xyuas thiab tshawb xyuas Medi-Cal tus kws kho mob thiab cov neeg tau txais txiaj ntsig kev dag, pov tseg, thiab kev tsim txom, hais txog kev tiv thaiv kev dag ntxias; ua kom muaj kev lav phib xaub ntawm lub xeev thiab tsoomfwv cov nyiaj pab kev noj qab haus huv los ntawm kev rov qab tau txais cov nyiaj them ntau dhau; ua kev tshuaj xyuas ntawm qhov chaw raws li ib feem ntawm Medi-Cal tus kws kho mob cov txheej txheem rau npe; muab kev pab cuam (nyiaj txiag thiab kho mob) rau kev txhim kho thiab txhim kho DHCS cov kev pab cuam noj qab haus huv thiab lwm txoj cai; thiab muab kev pab cuam thiab kev tshuaj xyuas cov ntaub ntawv los txhawb kev pab nyiaj txiag kev noj qab haus huv thiab cov hom phiaj xws li kev teeb tsa tus nqi kho mob.​​ 

Kev faib​​ 

A&I yog suav nrog cov kev faib tawm hauv qab no thiab pawg tswj hwm kev txhawb nqa.​​  

  • Contract and Enrollment Review Division (CERD) conducts state mandated medical and compliance reviews and audits to verify compliance with contractual requirements for the Drug Medi-Cal Organized Delivery Systems and medical, dental and behavioral health managed care plans. Other work performed by CERD includes federally mandated post-service, post-payment behavioral health utilization reviews; provider enrollment onsite reviews of high and moderate risk prospective Medi-Cal providers; onsite reviews for site certification and recertification of county-owned or operated Specialty Mental Health providers; and other requested third-party contract compliance reviews.​​ 
  • Financial Review Inpatient Division (FRID) conducts financial and compliance reviews and audits of Medi-Cal and other DHCS programs’ inpatient providers (acute hospitals and long-term care facilities). These reviews and audits verify that payments to providers and their reported costs are valid, accurate and in compliance with governing laws, regulations, and program intent. Audited data is also provided to assist with provider rate setting purposes.​​ 
  • Financial Review Outpatient and Behavioral Health Division (FROBHD) conducts financial and compliance reviews and audits of Medi-Cal and other DHCS programs’ outpatient and behavioral health providers, including Federally Qualified Health Centers, Rural Health Clinics, Local Educational Agency, Targeted Case Management, Ground Emergency Medical Transportation, Specialty Mental Health, Substance Abuse Prevention and Treatment Block Grant, and Drug Medi-Cal Organized Delivery System. These reviews and audits verify payments to providers and their reported costs are valid, accurate and in compliance with governing laws, regulations, and program intent. Audited data is also provided to assist with provider rate setting purposes.​​ 
  • Investigations Division (ID) conducts administrative and criminal investigations to address fraud, waste, and abuse in Medi-Cal and other DHCS programs. Specific activities include fraud data analytics, Medi-Cal fraud Hotline and complaint intake, investigative audits, provider fraud investigations, and beneficiary fraud investigations.​​ 
  • Kev Pabcuam Kev Tswj Xyuas Kev Tswj Xyuas Cov Tswv Cuab npaj, qhia, thiab tswj xyuas cov kev pabcuam kev tswj hwm los txhawb A&I, suav nrog kev tshaj tawm txog kev siv nyiaj txiag thiab kev taug qab, kev yuav khoom, kev cog lus, kev saib xyuas tus as-qhauj, kev cai lij choj, tib neeg cov peev txheej, kev tshuaj xyuas sab nraud, kev cob qhia, kev tshaj lij thiab kev tsim kho, kev tsim lub vev xaib, cov ntaub ntawv kev tshaj tawm, cov ntaub ntawv pej xeem ua raws li kev thov, thiab kev ua haujlwm hauv chaw.​​ 

Qhia Medi-Cal Fraud​​ 

Kev Noj Qab Haus Huv Kev dag yog kev ua txhaum cai.​​