To report medical fraud in California, you contact a different agency depending on who was defrauded: the Department of Health Care Services or the Attorney General’s Bureau of Medi-Cal Fraud and Elder Abuse for Medi-Cal, the U.S. Department of Health and Human Services Office of Inspector General for Medicare, and the California Department of Insurance for private health insurance or Workers’ Compensation. Picking the right office matters, because each has limited jurisdiction and a complaint sent to the wrong agency can sit while the clock runs. The good news is that California law shields good-faith reporters from civil liability and retaliation, and in some cases pays them a share of the money recovered.
Reporting Medi-Cal Fraud
Two state agencies handle Medi-Cal fraud, and either one will take your complaint.
The California Department of Health Care Services (DHCS) runs the Medi-Cal program and operates a fraud hotline at (800) 822-6222. You can also file online through the DHCS “Stop Medi-Cal Fraud” portal. This is the fastest route for straightforward complaints, such as a provider billing for a visit that never happened or a beneficiary lending out their Medi-Cal card.
The Attorney General’s Bureau of Medi-Cal Fraud and Elder Abuse (DMFEA) handles more complex schemes and cases involving elder abuse. Its hotline is (800) 722-0432, and it accepts online complaints through the Attorney General’s website.1State of California – Department of Justice – Office of the Attorney General. DMFEA Contact Us If you are not sure which office fits your situation, pick either. The two coordinate, and DHCS can refer a matter to DMFEA when it involves criminal conduct worth prosecuting.
Reporting Medicare Fraud
Medicare is a federal program, so Medicare fraud is reported to the U.S. Department of Health and Human Services Office of Inspector General (OIG), which investigates fraud, waste, and abuse across HHS programs including Medicare and Medicaid.2HHS Office of Inspector General. Fraud The OIG fraud hotline is 1-800-HHS-TIPS (1-800-447-8477), and complaints can also be filed through the OIG’s online “Report Fraud” portal.3HHS Office of Inspector General. Contact Us
If you are a Medicare beneficiary and you are not sure whether a charge on your Medicare Summary Notice is a mistake or something worse, California’s Senior Medicare Patrol (SMP) program offers free one-on-one counseling. SMP counselors help you read your statements, flag suspicious billing, and refer confirmed fraud to the appropriate federal or state agency.4Senior Medicare Patrol. What SMPs Do
Reporting Private Insurance Fraud
Fraud involving private health insurance or Workers’ Compensation is handled by the California Department of Insurance (CDI) Fraud Division. To report, download the Consumer Insurance Fraud Reporting Form from the CDI website and mail it to the Enforcement Branch Headquarters Intake Unit in Sacramento. The Fraud Division also takes reports by phone at (916) 854-5760.5California Department of Insurance. Reporting Fraud
You are protected when you file. Under Insurance Code Section 1879.5, you cannot be held civilly liable for reporting suspected insurance fraud to the CDI as long as the report is made in good faith.5California Department of Insurance. Reporting Fraud The statute exists so people can report without worrying about a defamation suit from the person or company they named.
Medical Privacy Violations Go to a Different Office
Not every problem with a provider is fraud. If what happened to you is a misuse of your health information rather than a billing scheme, that is a HIPAA matter and goes to the U.S. Department of Health and Human Services Office for Civil Rights (OCR). Complaints must be filed within 180 days of when you learned about the violation, though the OCR can extend the deadline for good cause. You can file online through the OCR Complaint Portal, email OCRComplaint@hhs.gov, or mail a written complaint. Covered entities are prohibited from retaliating against you for filing.6U.S. Department of Health and Human Services. How to File a Health Information Privacy or Security Complaint
What to Gather Before You Report
The more specific your report, the faster an agency can act. Before you call or submit a form, pull together whatever you have:
- Full name, address, and phone number of the provider, clinic, pharmacy, or facility.
- The specific dates when the suspicious billing or treatment occurred.
- A clear, factual description of what you believe happened. “I was billed for three physical therapy visits on dates I was out of state” is far more useful than “I think my doctor is committing fraud.”
- Copies of medical bills, Explanation of Benefits statements from your insurer, or Medicare Summary Notices showing the disputed charges.
- Names and contact information for anyone else who may have seen what happened, such as other patients or clinic staff.
You do not need a complete evidence file. Agencies would rather receive an incomplete tip they can investigate than hear nothing at all. Specific dates and document numbers simply give investigators a concrete starting point.
What Happens After You File
Once a complaint reaches the agency, staff screen it to decide whether a formal investigation is warranted. That initial review can take weeks. If a case opens, auditors, special agents, and prosecutors may gather records, interview witnesses, and build evidence over months. Most agencies will not send you ongoing updates. Confidentiality rules and the needs of an active investigation limit what they can share, so silence is not a sign your report was ignored.
Outcomes range from billing corrections and administrative penalties to civil lawsuits and criminal prosecution. Providers found guilty of fraud can lose their license and be excluded from federal healthcare programs, which blocks federal reimbursement for anything they bill.
Protections If You Work in Healthcare
Many of the most useful fraud reports come from inside a clinic, hospital, or billing office. If you work in healthcare and are worried about losing your job, California Labor Code Section 1102.5 prohibits employers from retaliating against employees who report suspected violations of state or federal law to a government agency or to someone inside the organization with authority to investigate. Retaliation includes firing, demotion, suspension, and threats. An employer who retaliates can be ordered to reinstate the employee, pay lost wages, and face a civil penalty of up to $10,000 per employee for each violation.7California Legislative Information. California Code LAB 1102.5 – Employee Whistleblower Protections
When Reporting Comes With a Reward
California and federal law both let private citizens sue on the government’s behalf to recover money stolen through fraud. These are called qui tam actions. They are filed under seal, meaning the complaint stays confidential while the government investigates, which protects your identity during the early stages. Most whistleblowers work with an attorney on contingency, so there are no upfront legal costs.
California False Claims Act
The California False Claims Act covers fraud against state and local government programs, including Medi-Cal. A defendant is liable for three times the damages plus a civil penalty of $5,500 to $11,000 per false claim.8California Legislative Information. California Code GOV 12651 – False Claims Act Penalties A whistleblower who files a qui tam suit receives 15 to 33 percent of the recovery if the state joins the case, or 25 to 50 percent if the state declines and the whistleblower’s attorney carries it forward.9California Legislative Information. California Code GOV 12652 – Qui Tam Actions The Act also protects whistleblowers from retaliation.10State of California – Department of Justice – Office of the Attorney General. False Claims Unit
Private Insurance Fraud
California Insurance Code Section 1871.7 creates a separate qui tam path for fraud against private insurers. If the district attorney intervenes and the case succeeds, the whistleblower receives 30 to 40 percent of the recovery.11California Legislative Information. California Code INS 1871.7 – Insurance Fraud Qui Tam Actions
Federal False Claims Act
For fraud against Medicare or other federal programs, the federal False Claims Act applies. A whistleblower receives 15 to 25 percent of the recovery if the government joins the case, or 25 to 30 percent if it declines.12Office of the Law Revision Counsel. 31 U.S. Code 3730 – Civil Actions for False Claims If the case rests mostly on publicly available information rather than your own knowledge, the court can reduce the award to no more than 10 percent.