Audits & Investigations
Investigations Branch
"Common Sense Law Enforcement"
Provider Fraud
DHCS/IB investigates “preliminary” provider fraud complaints. After a preliminary investigation is completed and reasonable cause has been established to substantiate fraud, DHCS/IB works with DHCS, Medical Review Branch, assessing the complaint and addresses the potential fraud through the use of suspensions and withholds regulations. The case file is then referred to the California Department of Justice (DOJ) Bureau of Medi-Cal Fraud and Elder Abuse for criminal investigation. Some examples of provider fraud include giving “kickbacks” to providers or beneficiaries, overbilling, double billing and false billing for Medi-Cal services.
