Medi-Cal Fraud Could Cost $540M, Study Finds
More than 3% of Medi-Cal billing by health care providers could be fraudulent at a cost to the state of $540 million annually, according to a Department of Health Services report released Friday, the Sacramento Bee reports.
The study analyzed a sample of payments to Medi-Cal providers, finding that:
- An additional $700 million likely was paid for claims made in error;
- A scheme at some pharmacies to provide less medication than prescriptions required; and
- Some adult day care centers and other health care providers billed for services that did not appear to be medically necessary.
DHS spokesperson Ken August said the increase this year was due to improved fraud-detection methods, rather than an increase in illegal billing (Benson, Sacramento Bee, 7/15).
This year's study focused more on high-risk provider categories and a more standardized review process that included comprehensive reviewer training and additional beneficiary-eligibility reviews, according to a Health and Human Services Agency release (Health and Human Services Agency release, 7/14).
The state was expected to recoup about $138 million last year from providers who made false claims.
Gov. Arnold Schwarzenegger (R) on Friday called for more auditing of the program and increased efforts to prevent and detect fraud (Sacramento Bee, 7/15). Schwarzenegger ordered DHS immediately to:
- Begin conducting more secondary claims reviews to detect fraud earlier;
- Review pharmacies on site to ensure compliance with state regulations;
- Adopt new anti-fraud technology to identify potential fraud schemes;
- Collaborate with the Legislature to revise payment methodology and monitoring of adult day health care centers; and
- Develop a joint plan of action with regulatory boards and provider associations to address provider claim errors (Health and Human Services Agency release, 7/14).