CWES Fraud Referrals - General

Overview

The CalWIN Referral Subsystem is to be used to initiate General Fraud Referrals to the SSA’s SIU as part of the prevention and detection of fraud.

The intent of the fraud referral process is to facilitate the prompt investigation and possible prosecution of welfare fraud. Following the processes and procedures in this chapter helps ensure that:

• Fraudulently obtained supportive services are kept to an absolute minimum, and
• The rights of the client are maintained.

Prior to Referral

Prior to making a referral for fraud, the EC must review the following sections:

• Pre-Referral Requirements.
• CWES Fraud Referrals - Fraud Indicators.
• “When to Refer” (below).

This will ensure that the referral is appropriate and help to avoid erroneous referrals, based on case management problems or administrative errors.

Evaluation of Information

After the information to determine eligibility for supportive services has been gathered and reviewed, the EC must make a number of determinations based on available data.

Some common determinations which must be made by the EC are:

• Is the client eligible for supportive services provided/paid?
• If the client is eligible, what is/was the correct amount of supportive services?
• If the client is ineligible or the amount of supportive services paid was incorrect, is there an overpayment?
• If an overpayment has occurred, can it be corrected by repayment?
• If an overpayment has occurred, are there reasonable grounds to suspect fraud?

When to Refer

The EC is to refer the case for investigation when the information provided by the individual is clearly inconsistent or in conflict with other information known to the agency, and the EC is unable to resolve this inconsistency or conflict with an explanation from the individual or third party.

Note: A denial of the allegation by the individual is not always a resolution of the discrepancy and may require a referral to the SIU for follow-up.

After the information is evaluated, a decision must be made as to whether there are reasonable grounds to suspect fraud.

Fraud Referral Information

General Fraud referrals to the SIU MUST have the reason for the referral entered on the [Referral Notes] tab in CalWIN: In the first sentence state whether the referral is a CWES Child Care, Transportation, or Ancillary Expenses fraud referral and all the details of the circumstances.

In the available space of the [Referral Notes] tab, add reference to specific information that will support the allegation and that will help SIU in an investigation. The specific information and/or reference details includes, but is not limited to:

• Location of documents in IDM (e.g., Fastener) and entry date
• “Community Compliant” (SCD 16)
• “Attendance and Child Care Billing” (SCD 1755)
• Reference to any previous fraud referral
• Driver’s license with picture (if available)
• Social Security Card of child care provider
• Check stubs
• Any other pertinent information.

Initiating a Fraud Referral

The following steps describe the process for initiating a fraud referral once a determination has been made that fraud may exist:

A. The EC:

• Makes an online referral to the SIU via the CalWIN Client Referral subsystem, by selecting Provider Name, SIU.
• Selects Fraud-CWES Referral from the Need drop-down field.
• Documents on the Maintain Case Comments window in CalWIN that a CWES Fraud Referral was initiated.
• Enters the details of the Fraud Referral in the [Referral Notes] tab in the available space in CalWIN as follows:
• CalWIN Case Name and Number
• Worker Name and Number
• Reason for fraud referral
• Specific detailed information that supports the allegation and that will help SIU in an investigation. Refer to “Fraud Referral Information” above.

Note: If there is any urgency for information needed, that information should be included in the referral notes.

• Makes a referral to Collections via CalWIN if an overpayment has occurred and the amount is known, if appropriate. Refer to CWES Overpayment & Underpayment - Referral to Collections for details.

B. The SIU Investigator:

• Notifies the EC that the referral has been assigned and ask if there is any change in the situation.
• Conducts an investigation to gather facts that prove or disprove the allegations.
• Informs the EC verbally of the findings of the investigation.
• Completes an investigation report with all information which supports his/her findings, and once investigation is completed, the EC will be notified by an SIU investigator of their findings.
• Emails a copy of the report to the EC, including SIU contact information.

EC Action on Completed Investigation

Once the investigation is completed, a fraud referral report will be sent to the assigned EC for action.

• Evaluates the investigation report as it affects eligibility for supportive services. Seek clarification from the Investigator, if needed.
• Reviews all eligibility factors.
• Attempts to resolve any inconsistencies resulting from the investigation, that may affect eligibility/ineligibility for supportive services.
• Takes appropriate action to approve, deny or discontinue supportive services, based on SIU findings, and document the action taken on CalWIN Maintain Case Comments window.
• Sends an electronic CWES disposition response to SIU via CalWIN Client Referral System, by selecting referral [Need] “Fraud-Referral Disposition” with information on the action taken on the case.
• Submits the completed investigation report for IDM scanning following District Office procedures.

SIU Investigator Disagreement With EC Action