What is Medi-Cal Fraud?

Medi-Cal is the name of the State of California’s Medicaid program, as well as certain state healthcare programs. Medi-Cal is administered by the California Department of Health Services and accounts for more than $40 billion in annual expenditures – nearly one-quarter of the state’s entire budget. Medi-Cal provides health coverage for approximately one out of every six Californians.

Medi-Cal fraud is any type of fraud perpetrated on the Medi-Cal program, whether by healthcare providers or beneficiaries. Individuals who claim benefits beyond what they are entitled to should be reported directly to the State Attorney General’s Office or the Bureau of Medi-Cal Fraud and Elder Abuse. If the fraud is a more pervasive scheme by a healthcare provider, however, you should contact an attorney to explore possible actions under California’s False Claims Act (the “Act”), Cal. Gov’t Code §§ 12650-12656.

The assistance of an experienced and qualified attorney is critical because of the procedural complexities of the Act, the concern about protecting yourself from possible retaliation, and the potential for a monetary recovery based on your role in reporting and prosecuting the alleged wrongdoing.

Private Citizens Can Initiate Actions Under the California False Claims Act

The Act’s qui tam provision permits a whistleblower to file an action to recover money for the State. Lawsuits initiated by private whistleblowers have resulted in some of the most significant recoveries under the Act.

Your lawsuit would be filed under seal to permit the Attorney General or local prosecuting authority to investigate and, if warranted, intervene in the action. This means that your identity is not made publicly known during the period that the case remains under seal, which is typically between one to three years.

If the government decides to intervene in your case, you could be eligible to receive 15-33% of the proceeds of the action or settlement of the claim, depending upon the extent to which you and your lawyers substantially contributed to the prosecution of the action. Further, if the government decides not to intervene, you have the right to continue to prosecute the case on the government’s behalf, making you eligible for up to 50% of any recovery.

Will I Be Protected Against Retaliation If I File A Lawsuit?

Although no statute can actually prevent a retaliatory action by your employer, California has a well-developed structure designed to deter such actions and allow for significant recoveries if you can prove that your employer violated the statutory prohibitions.

In addition to provisions under the California False Claims Act itself, there are also protective provisions in the California’s Whistleblower Statute, Cal. Labor Code §§ 1102.5-1105 and under the California Health and Safety Code § 1278, et seq. (protecting medical staff, doctors and nurses from retaliation due to reporting activities that affect patient care and safety).

What Types of Conduct Violate the False Claims Act?

Unfortunately, the range of illegal conduct is as broad as the imagination and determination of the people trying to steal money from this important State healthcare program. Among the more typical schemes are:

-Billing for medical services or procedures that the patient never actually received;

-Billing for more expensive services than the ones the patient received (known as “upcoding”);

-Billing both a government healthcare program and a private medical insurance provider for the same claim;

-Actually providing and billing for services that the patient doesn’t need (involving both monetary fraud and likely patient harm);

-Providing goods that are not what they are represented to be; or

-Charging government healthcare programs marked-up prices for medical devices or supplies.

In addition to these fairly straightforward schemes, there are various statutes and regulations that prohibit payments (of cash or other incentives) for the purpose of soliciting patients or contracts covered by government healthcare programs or regulate referrals of business to labs, clinics or other entities in which a healthcare provider has a financial stake.

Have Evidence of Medi-Cal Fraud?

If you observe conduct that doesn’t seem legitimate, or you are pushed to provide care or bill in ways that do not seem appropriate, contact a qui tam lawyer to evaluate whether the conduct you see is fraudulent and illegal.

If you have discovered evidence of fraud committed against the government, you may be entitled to a substantial reward and the legal protections afforded to whistleblowers under state and federal laws. The attorneys at Berger Montague are nationally recognized for their work in Whistleblower/Qui Tam actions. For more information or to schedule your confidential consultation, contact us online or call us at (844) 781-3088.