MEDI-CAL FRAUD BUREAU: Rising Referrals Spur New Changes
With the number of referrals increasing and an intensified focus on long term care facilities, California's Medi-Cal Fraud division is undergoing several changes. One of the more noticeable changes is the name: the division has been renamed the Bureau of Medi-Cal Fraud and Elder Abuse, in part to reflect the "benign neglect in past administrations" regarding nursing homes, according to bureau director Collin Wong. Another, more significant change is the number of referrals the bureau receives from the Department of Health Services. The caseload has exploded over the last three years, seeing referrals jump from 142 cases in 1997 to 283 in 1998 and 485 in 1999. In the first 25 days of 2000, 104 were referred. Wong attributed the increase to new fraud investigative resources made available through the 1999-2000 budget. He said, "At this rate, we are talking about an estimated one-year total of 817 referrals, and we're not even talking about the additional resources proposed in the 2000-2001 budget." Under the growing workload, Wong is finalizing a new budget proposal that will include a provision to establish more positions in the bureau. Although he did not say exactly how many new positions would be created, he did say that it was a "conservative number," but enough to "adequately investigate and prosecute" the cases. In addition, Wong credited DHS with improving its preliminary investigations, accounting for the increase in the number of meritorious cases. He also indicated that a case priority system would not be established. "We don't want to be forced to develop priorities or prerequisites to be met before we consider taking on a case. ... We want to have a case handled on its merits and not on resource deficiencies." In response to health care providers' concerns about investigations launched off innocent billing mistakes, Wong said, "In order for fraud to occur, it has to rise to the level of criminal. ... If, in the course of our investigation, we determine an overbilling that has no intent to defraud Medi-cal, we are not going to pursue it" (California Health Care Monitor, 2/7 issue).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.