HOW TO FIGHT A NON-FRAUD MEDI-CAL SUSPENSION 

Dealing with a Medi-Cal suspension is stressful enough, but it is particularly frustrating when there are no allegations of fraud or billing abuse. In California, the Department of Health Care Services (DHCS) can temporarily suspend a doctor for purely administrative or "procedural" reasons.

Here is how to handle a temporary suspension where fraud is not the issue.

The "No-Fraud" Temporary Suspension

Under Welfare and Institutions Code § 14043.36, a doctor can be hit with a temporary suspension and deactivation of provider numbers for reasons that have nothing to do with "cheating the system."

Common "Non-Fraud" Triggers:

• Failed Unannounced Visits: If DHCS or its agents conduct an unannounced site visit and find that the office is closed during posted hours, or if they determine the location is "not operational," they can trigger an immediate temporary suspension.

• Application Discrepancies: If you are in the process of "Continued Enrollment" and there is a discrepancy in your paperwork that you fail to remediate within 60 days, DHCS may suspend you while they "investigate" the inconsistency.

• Failure to Disclose: If a doctor fails to disclose a minor administrative change (like a change in business ownership or a new satellite location) within the required timeframe, it can lead to a suspension for "failure to provide full and complete information."

• Medical Audit Deficiencies: Repeated findings of medical record-keeping deficiencies—even if they don't involve overbilling—can lead to a suspension if DHCS deems them a risk to patient care.

How to Challenge an Administrative Suspension

1. Request an "Informal Conference" Immediately

When fraud isn't the issue, the suspension is often the result of a "paperwork disconnect." Your first move should be requesting a meeting with the Provider Enrollment Division (PED).

• The Goal: Show that the "discrepancy" was a clerical error or that the "closed office" during a site visit was a one-time emergency.

• The Result: You are looking for a Rescission of the Suspension. If you can prove the office is functional and the paperwork is now accurate, DHCS has the discretion to lift the suspension without a formal appeal.

2. File the 60-Day Administrative Appeal

If the informal route doesn't work, you must file a formal appeal under W&I Code § 14043.65.

• Timeline: You have 60 days from the date of the notice to submit your written appeal.

• Burden of Proof: You must provide "clear and convincing" evidence that the grounds for the suspension (e.g., the supposed "non-operational" status) are factually incorrect. This usually requires photos of the clinic, patient logs, and utility bills to prove the practice is active.

3. "Aid Paid Pending" (Managed Care Context)

If you are part of a Medi-Cal Managed Care Plan (MCP), a suspension from DHCS usually forces the plan to terminate your contract.

• In some administrative cases, you can petition the Managed Care Plan to keep your status "active" while the DHCS appeal is pending, though this is difficult and requires high-level legal negotiation between the doctor, the plan, and the state.

Summary: Fraud vs. Administrative Suspensions

Important Caution

Even if the suspension notice doesn't use the word "fraud," DHCS often uses these "temporary" administrative suspensions as a "placeholder" while they look for fraud. Never assume it is "just a paperwork issue" until you have confirmed with a legal professional exactly what triggered the DHCS action.

For legal help with a Medi-Cal suspension call our physician law experts at the Law Office of Daniel Horowitz.  (925) 283-1863.