Beneficiary Fraud
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The Department of Health Care Services (DHCS)/Investigations Division (ID) investigates complaints and referrals of beneficiary fraud received from all sources; and performs data analytics to identify and investigate beneficiary fraud, waste and abuse within DHCS programs.
After a preliminary investigation is completed and a credible allegation of fraud (CAF) has been established, DHCS will refer the fraud case to the appropriate local law enforcement agency for criminal prosecution when warranted. In most cases, beneficiary fraud cases are referred to the respective county district attorney’s office.
Some examples of beneficiary fraud include:
- Providing inaccurate or untruthful information to fraudulently obtain Medi-Cal benefits.
- Seeking multiple prescriptions from various physicians and/or hospital emergency rooms for illicit purposes and/or due to addiction.
- Diverting legal prescriptions for illegal uses.
- In-Home Supportive Service providers that submit fraudulent timecards for services they did not render.
- Committing identity theft or intentionally using another person's identity to obtain Medi-Cal benefits.
