Medical Review Branch
The Medical Review Branch (MRB) focuses on maintaining program integrity within the Medi-Cal program through reviews, audits, inspections and surveys of non-institutional providers. Non-institutional providers include physicians, physician groups, laboratories, pharmacies, durable medical equipment providers and other allied health entities. Branch activities are designed to assure that state and federal dollars spent for services and goods in the Medi-Cal program are used for essential healthcare benefits in compliance with program rules, regulations and law.
Corrective actions may range from the application of utilization controls to the imposition of administrative sanctions. The Branch may also recover overpayments and apply civil money penalties where appropriate. Further, the MRB conducts pre and post enrollment inspections at the behest of the Provider Enrollment Division as well as annual medical audits of managed care plans for the Medi-Cal Managed Care Division. The reports from contract compliance audits are posted on the Managed Care Quality and Monitoring Division’s website.
MRB publishes a Legislative Anti-Fraud Report biennially which summarizes the effectiveness of Medi-Cal fraud control initiatives and activities within the Branch. This report is posted on Reports to the Legislature webpage.
At this time, MRB is not actively conducting the Medi-Cal Payment Error Study due to limited resources. The previous study measured overpayments in fee-for service Medi-Cal and estimated the percentage of fraudulent billing. MRB remains committed to program integrity efforts and is continuously retargeting resources in the most effective and efficient manner possible.
Resources:
Contact Information
Medical Review Branch
Audits and Investigations
1500 Capitol Avenue–MS 2303
P. O. Box 997413
Sacramento, CA 95899-7413
(916) 440-7460
Mateo Hernandez, Acting Branch Chief
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