"What happens when you report Medi-Cal fraud"

How to Report Medi-Cal Fraud in California

In this post, we will cover everything you need to know about Medi-Cal fraud in California, including types of Medi-Cal and IHSS fraud, how to report Medi-Cal fraud and what happens after you report fraud to the DHCS fraud investigators

Additionally, we will cover the consequences of Medi-Cal fraud in California.

This includes the penalty and punishment for fraud, including misdemeanor and felony jail time and fines.

Lastly, we will provide data on cases brought by the fraud unit and the high number of convictions they have been able to obtain for cases between 2015-2020.

"How to Report Medi-Cal Fraud in California"

Table of Contents:

  • Types and Examples of Medi-Cal Fraud in California
  • How to Report Medi-Cal Fraud
  • What happens when you report Medi-Cal fraud?
  • What are the consequences of Medi-Cal fraud?
  • Medi-Cal Fraud Prosecutions in California

Types and Examples of Medi-Cal Fraud in California

Here is what constitutes Medi-Cal fraud, broken down by category:

Fraud Committed by Medi-Cal Beneficiary / Recipient

While most Medi-Cal beneficiaries are honest people who need quality health care, there are people who commit fraud or become involved in fraudulent schemes.

Here are the types of beneficiary Medi-Cal fraud:

Income Limits

Medi-Cal beneficiaries may exceed the Medi-Cal Income or Asset Requirement and still receive benefits they are not eligible for:

That is because there are situations where a beneficiary does not report some income or assets to their county worker.

This is considered fraud.

Identity Theft

Another way beneficiaries commit Medi-Cal fraud is by using another person’s personal information to get Medi-Cal benefits.

Sometimes the person whose identity was stolen is not aware until they begin to receive mail from the Medi-Cal program.

Fraud Committed by Medi-Cal Providers

Most Medi-Cal providers are honest in their billing practices and provide quality health care to their patients.

However, a relatively small number of providers commit fraud directly or become involved in fraudulent schemes.

The following are some types of known Medi-Cal provider fraud:

Capping

This is where a provider recruits and pays patients money or offers gifts in exchange to participate in the Medi-Cal program.

It is also illegal for an individual to receive payment or gifts to participate in the Medi-Cal program.

Balance Billing

This is where a provider charges a Medi-Cal beneficiary for the difference between the Medi-Cal reimbursement rate and the customary charge for the service.

Provider Illegally Billing Medi-Cal

This may be in the form of:

  • Providers ordering unnecessary lab tests
  • Dentists performing unnecessary teeth extractions on both adults and children
  • Medical supply companies billing for equipment and products that were neither ordered nor delivered

Fraud Committed within the Medi-Cal IHSS Program

Most Medi-Cal recipients and providers who are in the In-Home Supportive Services (IHSS) program are honest in their practices.

However, there are some providers as well as recipients who may violate the IHSS rules and commit fraud. The following are different types of IHSS fraud:

IHSS Beneficiary

Fraud committed by IHSS beneficiaries includes:

  • An IHSS beneficiary who does not really need services
  • An IHSS beneficiary who demands any portion of the provider’s check

IHSS Provider

Fraud committed by IHSS providers includes:

  • A provider is not doing the work but is getting paid.
    Some examples are a provider living too far away from the beneficiary to provide the services or a provider billing for services while the beneficiary is hospitalized or out of the country.
  • A provider is forging the beneficiary’s name on the IHSS timesheet.

How to Report Medi-Cal Fraud

Call the Medi-Cal Fraud Hotline at 1-800-822-6222.

When you call, make sure you know the types of fraud you are reporting – see above for examples/types of Medi-Cal fraud.

​The Department of Health Care Services (DHCS) asks that anyone suspecting Medi-Cal fraud, waste, or abuse to call the DHCS Medi-Cal Fraud Hotline at 1-800-822-6222.

If you feel this is an Emergency please call 911 for immediate assistance.

The call is free and the caller may remain anonymous.

The recorded message may be heard in 10 other languages: Spanish, Vietnamese, Cantonese, Armenian, Hmong, Cambodian, Laotian, Farsi, Korean, and Russian.

What happens when you report Medi-Cal fraud?

Here’s how Medi-Cal fraud cases are processed/handled in California:

Once you report Medi-Cal fraud in California, the Staff at DHCS Stop Medi-Cal Fraud Intake Unit handles all inquiries regarding Medi-Cal Fraud.

The unit receives hundreds of fraud complaints daily by:

  • E-mail
  • The Stop Medi-Cal Fraud and IHSS Fraud Hotlines
  • Hard mail, and
  • Directly from various other agencies.

Here’s how Medi-Cal fraud cases are handled.

  • The Intake Unit responds to all inquiries, calls, and e-mails
  • Staff processes the information and inputs it into a tracking database
  • As needed, staff will contact the reporting party to verify, seek or clarify information
  • Staff analyzes the complaint and determines if it should be referred to one of the regional Audits and Investigations offices for investigation and resolution.
  • Investigators interview witnesses, evaluate claims data, conduct data searches and perform other investigation activities.
  • If sufficient evidence exists, A&I will refer the case to the Department of Justice or to a local District Attorney’s Office

Due to HIPAA and Law Enforcement guidelines, Intake Unit Staff are unable to provide the status or resolution of a complaint.

What are the consequences of Medi-Cal fraud?

Most forms of Medi-Cal fraud are charged as either misdemeanors or felonies under California law.

The potential felony prison sentence for most forms of Medi-Cal fraud is anywhere from sixteen (16) months to five (5) years.

Additionally, felony fines can go up to fifty thousand dollars ($50,000), or double or triple the amount of the fraud.

In most cases, Medi-Cal fraud as a misdemeanor carries a potential county jail sentence of up to one (1) year.

Medi-Cal Fraud Prosecutions in California

Combating fraud and abuse of the California Medi-Cal program is a team of dedicated prosecutors, special agents, and investigative auditors in the Attorney General’s Division of Medi-Cal Fraud and Elder Abuse.

Under the direction of the Attorney General, the Division continues to be one of the most aggressive and successful health care fraud prosecutorial agencies in the nation.

Below is the number of Medi-Cal fraud cases the division has pursued, including conviction rate and restitutions from 2015 – 2020.

As you can see, the division has a very high conviction rate for Medi-Cal cases charged.

Fraud Cases:15/1616/1717/1818/1919/20
Criminal Filings16714818584101
Convictions1011301428985
Acquittals12101
Criminal Restitution$37,092,405$23,462,481$18,180,020$4,510,738$22,548,548
Civil Monetary Recoveries$109,061,258$47,042,246$50,856,185$44,390,093$17,132,129
Abuse and Neglect Cases:15/1616/1717/1818/1919/20
Criminal Filings96761017631
Convictions7653637033
Acquittals13610
Criminal Restitution$959,430$188,261$1,006,700$630,296$393,855

How to Report Medi-Cal Fraud Summary

We hope this post on How to Report Medi-Cal Fraud in California was helpful.

Questions?

If you have further questions about Medi-Cal, please let us know in the comments section below.

Be sure to check out our other articles about Medi-Cal and California Medicaid program, including:

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