主页个人审计和调查​​ 

审计和调查​​ 

了解计划完整性​​ 

使命​​ 

审计和调查 (A&I) 是加州医疗补助计划 – Medi-Cal 的指定项目诚信部门。 A&I 的使命是保护和加强 DHCS 管理的健康计划的完整性。 为了实现这一目标，A&I 执行财务和合规审计，包括对 Medi-Cal 提供商的服务后付款使用情况审查；对医疗、牙科和行为健康管理式医疗计划进行合规和医疗审计；识别和调查 Medi-Cal 提供商和受益人的欺诈、浪费和滥用，强调欺诈预防；通过追回已发现的超额支付确保州和联邦医疗保健资金的责任；作为 Medi-Cal 提供商注册过程的一部分进行现场审查；为 DHCS 健康计划和相关政策的制定和加强提供技术援助（财务和医疗）；并提供技术援助和审计数据以支持医疗保健融资计划和目标，例如提供商费率制定。​​ 

部门​​ 

A&I 由以下部门和行政支持部门组成。​​  

  • 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.​​ 
  • 行政管理服务处负责规划、指导和协调行政服务以支持 A&I，包括预算报告和跟踪、采购、合同、订阅账户监控、立法、人力资源、外部审计协调、培训、专业和组织发展、网站开发、数据发布、公共记录法案请求和设施运营。​​ 

举报 Medi-Cal 欺诈​​ 

医疗保健欺诈是一种犯罪行为。​​