DISABILITY AND HEALTHCARE INSURANCE FRAUD PROGRAM
According to Section 1871(h) of the California Insurance Code, health insurance fraud is a particular problem for health insurance policyholders.  Health care fraud causes losses in premium dollars and increases health care costs unnecessarily.

As mandated by California Insurance Code Section 1872.85(a), funding for the Disability and Healthcare Fraud Program is derived from an assessment of 10 cents annually for each insured under an individual or group insurance policy issued in the State.  This funding supports criminal investigations statewide by the Fraud Division and prosecution by district attorneys of suspected fraud involving disability and healthcare fraud.

This program area includes Suspected Fraudulent Claims involving: claimant disability other than workers' compensation, dental claims, billing fraud schemes, immunization fraud, unlawful solicitation, durable medical equipment, and posing as another to obtain benefits.

During Fiscal Year 2010-11, the Fraud Division identified and reported 355 SFCs, assigned 32 new cases, and made 15 arrests and 12 referrals to prosecuting authorities.  Potential loss amounted to $13,600,063.

District Attorneys' Disability and Healthcare Program

In Fiscal Year 2010-11, five counties received funding totaling $1,712,000 through the Department's Disability and Healthcare Insurance Fraud Grant Program.  The district attorneys reported 142 investigations, 62 arrests, and 50 convictions, which also included a majority of Fraud Division arrests.  Chargeable fraud amounted to $239,611,229 with $4,087,726 restitution ordered by the courts.

Organized Disability Insurance Fraud Assessment Grant Program Regulations