​​Audits & Investigations

Investigations Branch

Medi-Cal Beneficiary Fraud

Types of beneficiary fraud we investigate.

• ​Early Fraud Detection Program (EFDP)
• Applications for Medi-Cal benefits are reviewed at the county level prior to eligibility being established. County eligibility workers refer suspicious applications to DHCS/IB, whose investigators verify California residency, household composition and income/employment to ensure that applicants meet eligibility criteria.
•  Income Eligibility Verification System (IEVS)  
• Utilizing the Franchise Tax Board and Internal Revenue Service data, IEVS matches Medi-Cal beneficiary information with nationwide asset information and statewide employment data to determine if individuals are eligible to remain in the Medi-Cal program. IB submits its findings for criminal prosecution and/or recovery of monies expended when a beneficiary is discovered to be ineligible for services.
• Failure to report other insurance coverage 
• Often, beneficiaries will not report other health insurance coverage due to a share of cost that other coverage requires.
• Drug Diversion  
• Diversion of legal pharmaceuticals for illegal purposes is an escalating health and law enforcement issue. DHCS/IB utilizes computerized data analysis, surveillance, covert operations, informant management and interrogation of convicted/suspected beneficiaries to investigate Medi-Cal beneficiaries who seek multiple prescriptions from various physicians and hospital emergency rooms.
• In Home Supportive Services 
• County departments of social services authorize certain Medi-Cal beneficiaries to receive services at home rather than placing an individual in long term care. Providers of these services can be friends and/or relatives. Some providers and/or beneficiaries engage in fraudulent behavior such as receiving payment for services not rendered; falsification of “time cards” with or without the permission of the recipient of the services, creation of multiple identities in order to receive payment for IHSS and receiving payment for providing services to dead individuals. In some instances, both the provider and beneficiary are involved in the fraudulent scheme.
• Vital Statistics Investigations  
  
• IB investigators are notified by the California Department of Public Health, Vital Statistics, and various law enforcement agencies, county welfare departments, the Department of Motor Vehicles and county coroners, of possible fraudulent or altered vital statistics documents. Suspects who alter documents do so to avoid apprehension for criminal activities, to obtain aid and benefits which they are not entitled to or to stay in the country illegally.