Medi-Cal Fraud
The Medi-Cal Program
In California, the Medicaid program is known as Medi-Cal. Medicaid was enacted by Congress in 1965 to provide a comprehensive range of medical services to America's disabled and poorest citizens. It is often confused with Medicare, the federal health insurance program for the elderly. However, unlike Medicare - which is 100 percent federally-funded and provides the same benefit coverage throughout the country - Medicaid is jointly financed by federal and state funds and is administered by each state.
California's Medi-Cal program is an essential component in the delivery of health care to millions of low-income adults and children, the elderly, and the disabled. Administered by the state Department of Health Services, Medi-Cal accounts for more than $29 billion in annual expenditures - nearly one-quarter of the state's entire budget - and provides health coverage for approximately one out of every six Californians.
Report Fraud & Abuse
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.
According to the United States General Accounting Office and health insurance industry sources, between 3% and 10% of any state's Medicaid budget is lost due to fraud and abuse. Based on these figures, California's Medi-Cal losses can reach billions of dollars annually.
The financial burden for health care fraud lands firmly on the shoulders of the people of California in the form of higher premiums for health insurance and increased taxes for social programs. For those needing health care services, Medi-Cal fraud means the loss of already scarce funds to pay for vital services. There are also direct public health risks created by those who turn a profit by re-using syringes, performing needless medical procedures, or assigning unqualified staff to provide treatment.
Combating fraud and abuse of the state's Medi-Cal program is a team of dedicated prosecutors, special agents and forensic auditors in the Attorney General's Bureau of Medi-Cal Fraud and Elder Abuse.
Nationally recognized as being innovative and cutting-edge in its law enforcement approaches, the Bureau of Medi-Cal Fraud and Elder Abuse aggressively pursues criminals who are directly or indirectly involved in filing false claims for medical services, drugs, or supplies. These perpetrators can be registered Medi-Cal providers who allow others to use their billing privileges, or crooks who manage to tap into the billing privileges of registered providers. They can be identity thieves who steal information from providers and patients, or beneficiaries who accept payment for using a particular provider or for selling their Medi-Cal identities. Suspects can encompass anyone who is involved in the administration of the Medi-Cal program, including government workers and employees of contracting agencies.
Under the direction of the Attorney General, the Bureau entered the new millennium as one of the most aggressive and successful health care fraud prosecutorial agencies in the nation.
| BMFEA 1999-2006 | 98/99 | 99/00 | 00/01 | 01/02 | 02/03 | 03/04 | 04/05 | 05/06 |
| Criminal Filings (1) | 86 | 123 | 150 | 115 | 122 | 127 | 127 | 94 |
| Convictions | 44 | 88 | 95 | 87 | 101 | 85 (3) | 78 | 65 |
| Acquittals | 2 | 0 | 0 | 0 | 1 | 2 | 1 | 0 |
| Criminal Restitution | $6,197,603 | $27,475,076 | $6,693,688 | $11,983,883 | $23,651,391 | $35,498,020 | $5,277,934 | $6,525,097 |
| Civil Monetary Recoveries | $3,593,991 | $1,976,523 | $2,712,347 | $8,359,140 | $20,683,320 | $42,636,219 | $32,086,166 | $267,854,037 |
| BMFEA 1990-1998 | 90/91 (2) | 91/92 (2) | 92/93 (2) | 93/94 (2) | 94/95 (2) | 95/96 (2) | 96/97 | 97/98 |
| Criminal Filings (1) | 74 | 70 | 92 | 36 | 33 | 38 | 41 | 54 |
| Convictions | 60 | 57 | 54 | 47 | 30 | 27 | 49 | 45 |
| Acquittals | 0 | 1 | 2 | 0 | 1 | 1 | 0 | 0 |
| Criminal Restitution | $4,045,459 | $12,145,538 | $5,502,009 | $1,187,306 | $5,457,643 | $2,300,319 | $9,001,861 | $5,722,737 |
| Civil Monetary Recoveries | $15,475 | $400,000 | $750,738 | $1,787,675 | $3,865,281 | $10,007,435 | $5,641,742 | $1,166,083 |
- (1) These statistics do not include results stemming from BMFEA's aid to other law enforcement agencies.
- (2) Preliminary results for fiscal year; Includes largest dollar amount ordered in 28-year BMFEA history.
- (3) Includes national record for longest prison sentence imposed in a Medicaid fraud case (18 years, 8 months)
- (4) The Civil Prosecutions Unit did not exist prior to the 1996/97 Fiscal Year.