Health care fraud by providers takes billions of dollars annually from the Medicaid program, but also impacts the public's health. California's version of Medicaid, Medi-Cal, is administered by the State Department of Health Services (DHS) to provide health care to the State's low-income population. In recent years, an unprecedented number of unscrupulous Medi-Cal providers have defrauded the program and created potentially serious public health concerns. Provider fraud schemes using identity theft impact the reputations, and finances, of honest health care providers. Fraudulent medical care (i.e., services not rendered or rendered without adherence to medical standards) impacts Medi-Cal beneficiaries and/or entire communities by failing to diagnose or treat actual medical conditions (e.g., hepatitis), causing harm (e.g., contaminated blood draws), and increasing the risk of epidemics (e.g., untreated communicable diseases). The DHS devised an innovative audit strategy and coordinated referral process to evaluate providers with suspicious Medi-Cal billing activity. The goal was to assure access to quality health care and stop fraudulent providers while not inhibiting the beneficiaries and honest providers. Teams composed of one medical professional and one investigator with peace officer status make onsite visits; these teams are uniquely qualified to assess both quality of care and business legitimacy. Quality of care concerns are referred to the professional licensing boards; evidence of fraud results in sanctions and/or referral for further investigation to the DHS Investigations Branch, the State Department of Justice, or the Federal Bureau of Investigation.
Learning Objectives: "At the conclusion of the session, the participant (learner)in this session will be able to: 1. Recognize at least five common Medicaid provider fraud schemes." 2. Describe how Medicaid provider fraud is potentially harmful to the public's health." 3. Develop a unique investigative team and coordinated audit/referral process to effectively contain and prevent Medicaid provider fraud."
Keywords: Health Care Quality, Medicaid
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: California Department of Health Services
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.