Fraud, Waste, & Abuse

State of California – Medi-Cal Fraud

Medi-Cal fraud is generally defined as the billing of the Medi-Cal program for services, drugs, or supplies that are:

• Unnecessary
• Not performed
• More costly than those actually performed
• Medi-Cal fraud also refers to paying and/or receiving kickbacks for Medi-Cal billing referrals.

Based on government and private studies, and on the hundreds of millions of dollars of fraud the Bureau of Medi-Cal Fraud and Elder Abuse frequently recovers in a single year, the amount stolen from Californians by Medi-Cal fraud could reach billions of dollars annually. 1

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Health care fraud costs the United States tens of billions of dollars each year. Some estimates put the figure close to $100 billion a year. It is a rising threat, with national health care expenditures estimated to exceed $3 trillion in 2014. Health care fraud schemes continue to grow in complexity and seriousness. The dedicated efforts of law enforcement are a major component of the fight against health care fraud.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a national Health Care Fraud and Abuse Control Program (HCFAC or the Program) under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS), designed to coordinate Federal, state and local law enforcement activities with respect to health care fraud and abuse. In its seventeenth year of operation, the Program’s continued success confirms the soundness of a collaborative approach to identify and prosecute the most egregious instances of health care fraud, to prevent future fraud and abuse, and to protect program beneficiaries…

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