​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Audits and Investigations

Missio​n

Audits and Investigations (A&I) is the designated Program Integrity Unit for Califor​nia’s Medicaid program –​ Medi-Cal. A&I’s mission is to protect and enhance the integrity of the health programs administered by DHCS. To carry this out, A&I performs financial and compliance audits, including post-service post-payment utilization reviews of Medi-Cal providers; performs compliance and medical audits of medical, dental and behavioral health managed care plans; identifies and investigates Medi-Cal provider and beneficiary fraud, waste, and abuse, emphasizing fraud prevention; ensures accountability of state and federal health care funding by recovering identified overpayments; performs onsite reviews as part of the Medi-Cal provider enrollment process; provides technical assistance (financial and medical) for the development and enhancement of DHCS health programs and related policy; and provides technical assistance and audited data to support health care financing initiatives and objectives such as provider rate setting.​

​​Divisions

A&I is comprised of the following divisions and administrative support branch. 

• 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.
  
• Administrative Management Services Branch plans, directs, and coordinates administrative services to support A&I, including budget reporting and tracking, purchasing, contracts, subscription account monitoring, legislation, human resources, external audits coordination, training, professional and organizational development, website development, data releases, public records act requests, and facility operations.