PC 830.3(H), HEALTH CARE SERVICES

In this new series of profiles, we spotlight the wide variety of California peace officer classifications that are defined under Penal Code Section 830 and represented by PORAC.

A peace officer for a total of 13 years, Investigator Robert Musso has more than six years of experience at the California Department of Health Care Services (DHCS), which is designated by the federal Centers for Medicare and Medicaid Services (CMS) as the state agency tasked with administering Medicaid in California.

What led you to a career in this classification?

After seven years of patrol experience, I was looking for a career that would allow me to dig deeper into investigations beyond the preliminary stages of an initial first responder’s actions. I also wanted to investigate more technical and complex cases, leverage technology, author search warrants, as well as work collaboratively with groups to investigate large fraud schemes. This career at DHCS intrinsically affords these challenges to me.

What specific powers, duties and responsibilities are granted to your classification under PC 830?

Our state peace officer authority is codified in PC 830.3(h). Our powers are essentially equal to any other California peace officer. Our mission is to protect the fiscal integrity of California’s Medicaid program, emphasizing fraud prevention. In addition to criminal investigations, we have many administrative remedies to recover money and address fraud, waste and abuse. One critical component, in my opinion, is the internal feedback loop to make necessary program changes to prevent program policy exploitation.

What specialized training or certifications are required for your job?

Aside from earning a POST certified peace officer academy certificate and ongoing perishable training requirements, there are no current requirements for training or certificates specific to health care fraud required. Ongoing training is often gained by investigators taking initiative to request relevant training content and seek other learning opportunities and mentorships.

Could you describe the primary jurisdictional boundaries and limitations of your authority?

Our authority extends across the entire state of California. DHCS has six field offices throughout the state; however, we do not have officially designated “beats” or areas of responsibility. Because health care fraud is prolific and dynamic, our work takes us to all parts of the state, often irrespective of field office geographic constraints. As a result, we are able to travel to investigate cases in various areas. Los Angeles is the area with the highest proliferation of fraudulent activities.

What unique challenges or safety considerations does your classification face?

Our role is unique in that many other Medicaid Single State Agencies (SSAs) across the country that perform our equivalent statutorily mandated functions are non-sworn. This creates an interesting dynamic where we have to balance our professional development and other intrinsic values with our requirements to refer “Credible Allegations of Fraud” (CAFs) to our designed Medicaid Fraud Control Unit (MFCU). Our authority and competency compared to DOJ is essentially equal. Since DHCS investigators work directly within the Medicaid program, we are more versed in what information is available and how to navigate the bureaucracy to obtain it more efficiently. This is because we have direct access to many systems and databases. This procedural flow can impact efficiency.

California’s designated MFCU is the California Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse (DMFEA). A CAF referral is sent to DOJ when DHCS determines it has met the threshold to send the referral to DOJ. This standard generally revolves around gathering minimal probable cause required for the issuance of any related search warrant. DHCS has made great strides in enhancing our collaborative relationship with DMFEA, which is also outlined in a documented Memorandum of Understanding (MOU). This enables us to take ownership and pride in our work by assisting an any capacity post-referral.

Because our peace officers are nested within a relatively small branch within DHCS’s large program primarily tasked with service delivery, we do not work for a law enforcement agency. Obtaining tools and training to reduce risk inherent in law enforcement work is a tougher sell, especially when the agency has not experienced any critical incidents of this nature.

How does your classification interact with other peace officer classifications during multiagency operations or mutual aid situations?

We work with local, county, state and federal agencies. We have also engaged in contractual task force officer (TFO) arrangements. For example, DHCS has contributed investigators to multiagency task forces with host agencies like the FBI and DEA. DHCS continues to maintain a reputation for being great to work with. We are particularly effective at mobilizing teams to perform large-scale field operations.

How has your classification evolved, and what emerging challenges do you anticipate?

Medicaid is a very expensive program for California to operate. Due to budgetary constraints, laws and regulations, we have seen a reduction in our force. We experienced an exponential increase in Medicaid beneficiary enrollments, but a decrease in program integrity staffing levels. The Affordable Care Act and other regulations have contributed to vast program expansion. We anticipate challenges in effectively and efficiently combating ever-growing fraud that is becoming more sophisticated and technical. I am a firm proponent of a vision of innovation implemented by leveraging technology as a critical component to a comprehensive solution.

What are some highlights of your job?

As it pertains to investigations, I enjoy the moments when I am behind a desk drilling into various forms of computer and communications data and have an “aha” moment when I am able to identify a possible suspect who made calculated efforts to evade detection. I enjoy teaching others these techniques, which will become increasingly valuable over time. I am especially rewarded by harnessing our talent, irrespective of title or rank, through leading broad collaborative change that benefits everyone in the organization.

What makes your classification integral to the overall public safety mission?

Our work is noble and so important, because the dollar loss amounts seen in health care fraud often dwarf other forms of white-collar financial crimes. We are talking about individual cases in excess of hundreds of millions of potential dollars at risk. The general public is often unaware of the sheer scope and scale of this type of fraud.

Are there any misconceptions you would like to dispel about your classification?

There is a lack of awareness by the public, health plans, county welfare departments and health care providers that the DHCS Investigations Division exists and what services we provide. Public service announcements that target vulnerable communities would be a great start, as these communities are exploited by criminals most often. We have an incredible amount of talent and untapped potential that we hope to unleash more in the future, especially as the next generation of leaders rise through our ranks.

We are not here to broadly take away services; we want to make sure every dollar can be spent for those who need it most. Health care is a public good that impacts quality of life for all of us. We believe in Medicaid and want it to be as effective as possible.