Audits & Investigations
Audits and Investigations Division (A&I) is the designated Program Integrity Unit (PIU) for the Medi-Cal program. A&I’s mission is protect and enhance the integrity of the health programs administered by the Department of Health Care Services (DHCS). A&I also strives to improve the effectiveness and efficiency of DHCS and the programs it administers. To carry out its mission and objectives, A&I:
- Performs financial and medical audits, including post-service post-payment utilization reviews, to ensure Medi-Cal program integrity.
- Performs annual medical audits of Medi-Cal managed care and dental 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 and recovers identified overpayments, where appropriate.
- Performs onsite reviews of select applicants 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.
- Provides technical assistance and audited data (internal and external) related to various aspects of health care financing and delivery.
- Provides assurance and advisory services to DHCS.
- Acts as liaison between DHCS and external oversight entities conducting audits and reviews of the Medi-Cal program.
A&I is comprised of five branches that include an independent Internal Audits branch within DHCS. Additionally, the division includes the Administrative Management Services Section (AMSS), which provides centralized administrative functions to A&I.
Financial Audits Branch (FAB) ensures, through financial audits, that payments made to providers of Medi-Cal or other State or federally funded health care programs are valid, reasonable, and in accordance with applicable laws, regulations, and program policy.
Investigations Branch (IB) is comprised of sworn Peace Officers who conduct criminal and administrative investigations of fraud and abuse by Medi-Cal beneficiaries. IB also conducts preliminary criminal investigations of Medi-Cal providers when warranted.
Medical Review Branch (MRB) is charged with performing federally mandated post service, post payment utilization reviews, state mandated annual medical audits of managed care plans, and provider enrollment onsite reviews.
- Special Investigations Unit (SIU) is a multi-disciplinary team that conducts targeted post payment reviews of Medi-Cal providers identified as having potential fraud, waste and abuse billings.
Internal Audits (IA) is charged with performing department-wide internal control reviews, special reviews, and consultation services to ensure DHCS risk management, governance, and control processes are operating effectively. IA is also responsible for external audit coordination.