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, and violations of the California False Claims Act and other related state laws.

Based on government and private studies, and on the hundreds of millions of dollars of fraud the Division 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

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 investigative auditors in the Attorney General's Division of Medi-Cal Fraud and Elder Abuse.

Nationally recognized as being innovative and cutting-edge in its law enforcement approaches, the Division 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. It also pursues hundreds of entities every year for unlawful acts constituting fraud under the California False Claims Act and other key statutes. These perpetrators can be registered Medi-Cal providers who allow others to use their billing privileges, or other actors 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 Division continues to be one of the aggressive and successful health care fraud prosecutorial agencies in the nation.

Fraud Cases: 15/16 16/17 17/18 18/19 19/20
Criminal Filings 167 148 185 84 101
Convictions 101 130 142 89 85
Acquittals 1 2 1 0 1
Criminal Restitution $37,092,405 $23,462,481 $18,180,020 $4,510,738 $22,548,548
Civil Monetary Recoveries $109,061,258 $47,042,246 $50,856,185 $44,390,093 $17,132,129
Abuse and Neglect Cases: 15/16 16/17 17/18 18/19 19/20
Criminal Filings 96 76 101 76 31
Convictions 76 53 63 70 33
Acquittals 1 3 6 1 0
Criminal Restitution $959,430 $188,261 $1,006,700 $630,296 $393,855

1, U:\Shared.dir\FET\Users\DicaV\Research\Misc\2015-08-06 Payment Accuracy medicaid-2014.pdf