CWES Fraud Referrals Policy

[EAS 20-000, 42-751, and 47-440]

State regulations require counties to refer suspected fraud associated with supportive service payments on the part of the client or provider for investigation and to take all reasonable steps necessary to promptly correct any overpayment of supportive services payments due to fraud.

It is county policy that CWES staff refer ALL open or PAS cases where fraud is suspected to SSA’s SIU regardless of the overpayment amount.

Note: The SIU will prioritize and investigate for criminal prosecution when warranted.

Definition of Fraud

Fraud is the knowing misrepresentation of facts with the intent to obtain something to which one is not entitled.

Fraud exists when an individual, on behalf of himself, or others:

• Knowingly, and with intent, makes a false statement or representation to obtain benefits, obtain a continuance or increase of benefits, or avoid a reduction of benefits or denial of benefits.
• Knowingly, and with intent, fails to disclose a fact which, if disclosed, could result in denial, reduction, or discontinuance of benefits.
• Accepts benefits knowing that he/she is not entitled, or accepts any amount of benefits knowing it is greater than the amount he/she is entitled to receive.

Fraud Prevention

To reduce the chance of fraud occurring, the EC must:

• Review the rights and responsibilities for the program with the client.
• Inform the client of what information is needed to determine eligibility for supportive services and why the information is needed.
• Explain to the client their responsibility to report correct and complete information and to promptly report changes in circumstances to the EC.
• Document the client’s perceived level of understanding of their reporting responsibilities in MaJournal Detail pageindow in CalWIN (i.e., “Client states that he fully and completely understands reporting requirements.”)
• Advise the client of the potential criminal penalties for making false statements or failing to report information.

Pre-Referral Requirements

Referrals to the SIU for fraud investigations are to be initiated by the EC as part of their role in the prevention and detection of fraud. The SIU investigates referrals of potential fraud by clients or others to determine potentially fraudulent receipt of public assistance (supportive services) and completes the prosecution of these claims as appropriate.

Following each step in the detection process is essential to the successful evaluation of fraud. When proper procedures are followed, erroneous referrals, based solely on eligibility problems or administrative errors, may be avoided.

Prior to initiating a referral to the SIU, the EC must review all information and:

• Analyze whether or not the information received is logical for the situation described.
• Check for the inconsistencies of statements contained in CWES documents pertaining to supportive services and other information provided by the individual.
• Pursue inconsistencies in information received and individual’s statements. Allow the individual an opportunity to clear up what may turn out to be a simple misunderstanding. It is only when a reasonable or credible explanation is not forthcoming that the EC must take further action.
• Clarify unexplained discrepancies. A denial of the discrepancy by the individual is not always a resolution of the discrepancy.
• Make third-party contacts to properly assess a situation, if appropriate. The EC must obtain a “Release of Information” (SCD 1029) to follow-up on third-party contacts.
• Treat all individuals with respect and dignity.

Note: If the issue remains questionable or unresolved, a fraud referral must be made by the EC.

Community Inquiry

Community complaints are defined as complaints received by persons in the community to report client fraud or misrepresentation by a staff member of this Agency. All community complaints are documented on the “Community Inquiry or Report” (SCD 16). Refer to Common Place Handbook, Chapter 39 for more information.

On occasion a member of the community may call-in an inquiry or complaint for suspected fraud to a CWES District Office or directly to an EC. The information may be provided by a neighbor, provider, relative, or any other member of the community.

In order to maintain the confidentiality of the client, the person taking the call must NOT acknowledge that the client is a recipient of any AGENCY services. These calls are to be routed to the CWES Fraud Designee for the CWES District Office.

The designated person must follow this process when a complaint is received: