Understanding California's Welfare & Institutions Code § 14107: Combating Fraudulent Claims in Medi-Cal

Welfare & Institutions Code § 14107 serves as a key criminal statute to deter and punish fraudulent activities involving Medi-Cal claims. Enacted within Division 9, Part 3, Chapter 7 (Basic Health Care) of the code, this section targets intentional fraud in submitting claims or obtaining payments from the program. This section targets fraudulent applicants and also enrolled providers.

[A Medi-Cal enrolled provider is a healthcare professional, organization, or facility that has been approved by California's Department of Health Care Services (DHCS) to provide services to Medi-Cal beneficiaries. After being approved, they are eligible to bill Medi-Cal for services rendered to eligible individuals, which can include doctors, dentists, hospitals, and various clinics. Providers must meet specific requirements and complete an application process, which is now primarily done online through the PAVE Provider Portal, to enroll.]

Who Does the Law Apply To?

The statute applies broadly to "any person," including:

1. Medi-Cal applicants or enrolled providers (as defined in § 14043.1)
2. Billing agents (as defined in § 14040.1)

[A § 14040.1 billing agent is an individual, entity, or their representative that submits claims to the Medi-Cal program on behalf of a service provider. These agents handle billing for services provided to Medi-Cal beneficiaries but are distinct from the provider's authorized representatives or wholly owned entities billing solely for their parent provider. Providers must enter into a written contract to use a billing agent and provide the state with written notification of the agent's information at least 30 days before claims are submitted.]

And there is a catch all provision which can involve anyone else involved in the prohibited conduct. (Such as office managers)

What Conduct Is Prohibited?

Subdivision (b) lists the specific activities that trigger penalties under the section:

1. Presenting false or fraudulent claims — Knowingly submitting a bogus claim for services or merchandise with intent to defraud.

2. Submitting false information for greater compensation — Providing false info to get paid more than legally entitled (e.g., upcoding services or billing for work not performed). This might involve overstating the complexity of a medical problem, treating for a short time but billing for a longer visit or even billing for visits that did not take place.

These acts mirror federal health care fraud statutes (like 18 U.S.C. § 1347) but apply specifically to California's programs. A violation of 18 U.S.C. § 1347 would be brought in federal court but the violation of Welfare & Institutions Code § 14107 would be brought in state court.