Code Section

12528.  

(a) There is in the Office of the Attorney General the Division of Medi-Cal Fraud and Elder Abuse, which shall implement Sections 1903(a)(6), 1903(b)(3), and 1903(g) of the federal Social Security Act, as amended by the federal Medicare-Medicaid Anti-Fraud and Abuse Amendments (Public Law 95-142), and is authorized to conduct a statewide program for investigating and prosecuting, and referring for prosecution, violations of all applicable laws pertaining to fraud in the administration of the Medi-Cal program, the provision of medical assistance or medical supplies, or the activities of providers of medical assistance or medical suppliers under the Medi-Cal state plan. The investigation of fraud by beneficiaries of the Medi-Cal program shall be the responsibility of the Audits and Investigations Branch of the State Department of Health Care Services.

(b) The division shall also review complaints alleging abuse or neglect of patients in health care facilities receiving payments under the Medi-Cal state plan, and may review complaints of the misappropriation of patient’s private funds in those facilities and complaints of discriminatory treatment of Medi-Cal beneficiaries by those facilities.

(1) If the initial review indicates substantial potential for criminal prosecution, the division shall investigate the complaint or refer it to an appropriate criminal investigative or prosecutive authority.

(2) If the initial review does not indicate a substantial potential for criminal prosecution, the division shall inform the referring agency of its determination and may, if appropriate, refer the complaint to the State Department of Health Care Services.

(c) Local law enforcement and prosecution agencies shall have concurrent jurisdiction with the division to investigate and prosecute violations of law specified in this section.

(d) If the division, in carrying out its duties and responsibilities under subdivisions (a) and (b), discovers that overpayments have been made to a health care facility or other provider of medical assistance or medical supplies under the Medi-Cal state plan, the division shall either attempt to collect the overpayment or refer the matter to the State Department of Health Care Services for collection.

(e) Where a prosecuting authority other than the division elects to prosecute a case reported to the division, the division shall, upon request of that prosecuting authority, ensure that those responsible for the prosecutive decision and the preparation of the case for trial have the opportunity to participate in the investigation from its inception and shall provide all necessary assistance to the prosecuting authority throughout all resulting prosecutions.

(f) The division shall make available to federal investigators or prosecutors all information in its possession concerning fraud in the provision or administration of medical assistance under the Medi-Cal state plan, and shall cooperate with officials in coordinating any federal and state investigations or prosecutions involving the same suspects or allegations.

(g) The division shall safeguard the privacy rights of all individuals and shall provide safeguards to prevent the misuse of information under its control. Agencies that are required to report complaints alleging abuse or neglect of patients shall maintain the confidentiality of those reports until a time that the report becomes a matter of public record.

(h) The division shall offer training programs to local law enforcement and prosecutorial personnel in investigating and prosecuting crimes against elders and dependent adults. The division shall offer training programs to the State Department of Health Care Services, the State Department of Social Services, the county adult protective services agencies, and the Long-Term Care Ombudsman in evaluating and documenting criminal abuse against elders and dependent adults.

(i) The state Long-Term Care Ombudsman, the Licensing and Certification Division in the State Department of Health Care Services, and the Statistical Services Bureau in the State Department of Social Services shall report to the division all instances of abuse and neglect of elders and dependent adults, as defined in Section 15610 of the Welfare and Institutions Code, which come to their attention.

(j) The division shall collect information on a statewide basis regarding cases of abuse and neglect of patients in health facilities receiving payments from the Medi-Cal program for the primary purpose of analyzing the information it collects and disseminating its conclusions to local law enforcement agencies and to regulatory and licensing authorities.

(k) For purposes of this section, “division” means the Division of Medi-Cal Fraud and Elder Abuse in the Office of the Attorney General.