Instituted in 1966, Medi-Cal is California's Medicaid program that is administered by the California Department of Health Care Services (DHCS), which provides public health coverage to low-income adults, children, and other eligible individuals located throughout the state. The program accounts for one-quarter of the state's fiscal budget and covers approximately one out of six California residents. However, the number of Medi-Cal fraud cases is on the rise, costing the State and its taxpayers almost a billion dollars each year.
Medi-Cal fraud is generally defined as the intentional efforts by medical providers, and in limited cases benefit recipients, to collect unlawful insurance money or program benefits. Although Medi-Cal fraud can take various forms, the most popular involves medical providers, including but not limited to doctors, medical laboratories, and hospitals, intentionally billing for services that were never rendered or charging for more costly services or products (also known as “upcoding”) that they never provided to patients.
As a result of the alarming increase in insurance fraud cases, the State of California created the Medi-Cal Fraud Task Force back in 1999 with the sole purpose of preventing, investigating, and combatting these types of violations. Participating members of this task force include the CDHS, the California DOJ, the FBI, and several others. As evident from the above, the State of California undoubtedly takes these cases very seriously, prosecuting many to the fullest extent of the law.
Despite the validity behind many DHCS Medi-Cal fraud investigations, there is a number that is based upon false accusations, an overtaxed bureaucracy, overzealous auditors/investigators, and unintended mistakes that have had devastating effects on law-abiding and ethical medical providers. Specifically, being accused of Medi-Cal fraud is a serious matter that without seasoned legal representation, can result in extensive prison time, harsh monetary fines, the temporary or permanent suspension of one's professional license, and irreparable damage to one's personal and professional reputations.
Depending upon the specific set of circumstances, an accusation of Medi-Cal fraud may result in the following legal consequences:
Extensive DHCS audits and investigations;
Administrative sanctions, including withholding payment to a medical provider and temporarily or permanently suspending their professional license;
Misdemeanor penalties, including summary probation, jail time of up to a year, a monetary fine of up to $10,000 (or three times the amount of fraudulently obtained money/benefits), and reclamation of fraudulently obtained assets; and
A felony conviction, with the institution of such penalties as jail time for more than one year (if bodily harm resulted from the fraud, the prison time can be even greater), monetary fines of $50,000 or double the monetary amount of the fraud, whichever is greater, and the forfeiture of fraudulently obtained assets.
In general, dealing with Medi-Cal audits and investigations, which are extremely different than the delegated contractor structure of the Medicare program, can be very confusing to physicians, dentists, pharmacists, and other medical providers, and may lead to inadvertent yet costly mistakes. In other words, when facing an accusation of fraud, it is highly recommended that you consult with a qualified attorney to help guide you through the process and launch a comprehensive and aggressive defense.
If you are facing any type of issue regarding Medi-Cal compliance, including suspensions, dis-enrollments, procedure code limitations, audits, or investigations, and criminal/civil charges, do not sacrifice your livelihood by representing yourself. Contact our office now to maximize your chances of successfully defending against a charge of Medi-Cal fraud.