Health care fraud is an issue that has been getting a great deal of attention lately. Since there are so many different aspects of health care fraud, it’s difficult to know exactly how big an issue it really is.
Health care fraud is a blanket term that’s used to describe businesses, organizations, and even individuals who do something to misrepresent their health care situation. Examples of health care fraud could include a business that charges for services that aren’t actually rendered, or someone who claims to have a medical condition but doesn’t, or deliberate coding problems that are designed to change claims/bills.
California’s Department of Health and Care Services is aware that health care fraud is a major problem and would like to stop it in its tracks. They are particularly concerned about Medi-Cal fraud and urge anyone who suspects they are being used in a fraudulent claim to contact DHCS Medi-Cal Fraud Hotline at 1-800-822-6222.
The DHCS has created a task force that is trained to handle all health care fraud allegations. The task force looks at all the tips they receive through different sources and identifies the ones they feel are the most concerning. These are the first cases they’ll investigate.
If the case merits additional investigation, the case is turned over to the Audits and Investigations offices. The investigation is detailed and methodical. Records are analyzed, witnesses give statements, data searches are initiated, and many claims undergo intensive scrutiny.
If the investigation uncovers enough evidence of health care fraud, the case will be turned over to the California Department of Justice who will determine if charges will be filed.
The exact consequences connected to health care fraud vary are as varied as the actual cases.
Businesses are often issued a court order that requires them to repay all of the money they collected by overbilling providers. If the business is allowed to retain its operating license, they will likely be required to submit to pre-payment reviews for an indefinite period of time. Most businesses will be required to appear before California’s licensing boards and could potentially lose their operating license.
It’s not uncommon for businesses that are convicted of health care fraud to be court-ordered to not only repay the money acquired via the fraud but to also be required to pay up to three times the financial amount of the money owed to the fraud victims.
Most businesses/individuals who are found guilty of health care fraud in California will be required to pay court-ordered legal fees and will also likely face civil charges and fees as well.