Provider Fraud
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The Department of Health Care Services (DHCS)/Investigations Division (ID) investigates complaints and referrals of provider fraud received from all sources; and performs data analytics to identify and investigate provider fraud, waste and abuse within DHCS programs.
After a preliminary investigation is completed and a credible allegation of fraud (CAF) has been established, DHCS is statutorily required pursuant to Welfare and Institutions Code 14107.11 to place a temporary payment suspension against the provider unless it is determined there is a good cause exception not to suspend the payments or to suspend them only in part. The establishment of a CAF also requires that DHCS send a fraud referral to the California Department of Justice (DOJ) Division of Medi-Cal Fraud and Elder Abuse, California’s designated Medicaid Fraud Control Unit, for further criminal investigation and prosecution when warranted.
Some examples of provider fraud schemes include:
- Knowingly solicit, offer, or pay a “kickback”, bribe, or rebate for furnishing services.
- Double billing by submitting multiple claims for the same service.
- False billing for Medi-Cal services or supplies that the beneficiary never received.
- Unbundling of services to maximize reimbursement for procedures that are required to be submitted together at a reduced cost
- Patient identify theft to submit claims for fraudulent goods or services.
