家個人審計和調查​​ 

審計和調查​​ 

瞭解計劃完整性​​ 

使命​​ 

審計和調查 (A&I) 是加州醫療補助專案 – 加州醫療補助健康保健計劃的指定專案誠信單位。 A&I 的使命是保護和增強DHCS管理的健康專案的完整性。 為此，A&I 進行財務和合規審計，包括對加州醫療補助健康保健計劃提供者的服務後付款後使用情況審查；對醫療、牙科和行為健康管理護理計劃進行合規和醫療審核；識別並調查加州醫療補助健康保健計劃提供者和受益人的詐欺、浪費和濫用行為，強調預防詐欺；透過追回已確定的多付款項，確保州和聯邦醫療保健資金的問責制；作為加州醫療補助健康保健計劃提供者註冊流程的一部分進行現場審查；為制定和加強DHCS健康專案及相關政策提供技術援助（財務和醫療）；並提供技術援助和審計數據，以支援醫療保健融資計劃和目標，例如提供者費率設定。​​ 

分部​​ 

A & I 由以下部門和行政支持分支組組成。​​  

  • 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.​​ 
  • 行政管理服務部規劃、指導和協調行政服務以支持 A & I，包括預算報告和追蹤、採購、合約、訂閱帳戶監控、立法、人力資源、外部稽核協調、培訓、專業和組織發展、網站開發、數據發布、公開記錄法要求和設施操作。​​ 

舉報加州醫療補助健康保健計劃詐欺行為​​ 

醫療保健欺詐是犯罪。​​