​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Audits & Investigations

Missio​n

Audits and Investigations Division (A&I) is the designated Program Integrity Unit (PIU) for the Medi-Cal program. A&I’s mission is protect and enhance the integrity of the health programs administered by the Department of Health Care Services (DHCS). A&I also strives to improve the effectiveness and efficiency of DHCS and the programs it administers. To carry out its mission and objectives, A&I:

• Performs financial and medical audits, including post-service post-payment utilization reviews, to ensure Medi-Cal program integrity.
• Performs annual med​ical audits of Medi-Cal managed care and dental plans.
• Identifies and investigates Medi-Cal provider and beneficiary fraud, waste, and abuse, emphasizing fraud prevention.
• Ensures accountability of state and federal health care funding and recovers identified overpayments, where appropriate.
• Performs onsite reviews of select applicants as part of the Medi-Cal provider enrollment process.
• Provides technical assistance (financial and medical) for the development and enhancement of DHCS health programs and related policy.
• Provides technical assistance and audited data (internal and external) related to various aspects of health care financing and delivery.
  

A&I is comprised of four branches that includes the Administrative Management Services Section (AMSS), which provides centralized administrative functions to A&I.

• Financial Audits Branch​ (FAB) ensures, through financial audits, that payments made to providers of Medi-Cal or other State or federally funded health care programs are valid, reasonable, and in accordance with applicable laws, regulations, and program policy.
  

• Investigations Branch​ (IB) is comprised of sworn Peace Officers who conduct criminal and administrative investigations of fraud and abuse by Medi-Cal beneficiaries. IB also conducts preliminary criminal investigations of Medi-Cal providers when warranted.
  

• Medical Review Branch​ (MRB) is charged with performing federally mandated post service, post payment utilization reviews, state mandated annual medical audits of managed care plans, and provider enrollment onsite reviews.

• ​​​​Special Investigations Unit (SIU) is a multi-disciplinary team that conducts targeted post payment reviews of Medi-Cal providers identified as having potential fraud, waste and abuse billings.