County of San Diego Health and Human Services Agency HHSA Cash Assistance Program for Immigrants CAPI Program Guide Fraud Prevention and Detection Number Page 991132 1 of 3 Revision Date October 1 2019 Background This section provides policies and procedures for reviewing cases for potential fraud in CAPI Purpose This section is revised for the sunset review No Program rules have changed Policy Fraud prevention and detection is a primary goal of HHSA Customers who change their statements regarding their current situation must clarify the information to establish eligibility It is the workers responsibility to ensure that all information in the case file is consistent Lack of clarification is cause for case denial or suspension If conflicting information exists it must be corrected or clarified by the customer or a referral must be made to Public Assistance Fraud Division PAFD 1 Definitions The table below shows the definition of some terms used in this section Note The person mentioned does not need to be the customer or anyone related to or acting on behalf of the customer Term Definition Fraud Exists when any person knowingly willfully and with intent to defraud Made or caused to be made a false statement to obtain benefits obtain a continuance or increase of benefits or avoid a reduction of benefits Failed to disclose or misrepresented a fact which could have resulted in a denial suspension or reduction of benefits Similar Fault Exists when any person Knowingly failed to disclose a fact which if disclosed could have resulted in a denial suspension or reduction of benefits Made statements that heshe knew to be untrue or incomplete during the process of obtaining benefits for continuing to obtain benefits Intent to defraud is not required 2 Workers Role in Fraud PreventionDetectionReferral Workers are responsible for issuing CAPI assistance to customers who meet all eligibility requirements There are times when the documentation is questionable or the customers information is not consistent In these situations inconsistencies must be clarified prior to issuing benefits Make every effort to ensure that the customer understands hisher responsibilities to provide accurate and truthful information and to report within 10 days any changes that may affect hisher eligibility andor grant amount The customer must understand the penalties for failing to report truthfully and promptly Review these responsibilities with the customer at each application and redetermination Document in the case record to show if the customer appeared to understand these responsibilities County of San Diego Health and Human Services Agency HHSA Cash Assistance Program for Immigrants CAPI Program Guide Fraud Prevention and Detection Number Page 991132 2 of 3 Obtain all verifications mandated by the program and review these verifications to determine if they are questionable inconsistent or appear to have been altered Attempt to resolve any conflicting inconsistent or incomplete information with the customer to the fullest extent possible Fully document all contacts responses from the customer and any additional information received as a result of contacts in the case record If the inconsistent or questionable information still cannot be resolved then initiate a fraud referral Information indicating that HHSA employees may have assisted customers to commit fraud or have committed fraud themselves must be elevated immediately to the Agencys Internal Investigations section All staff is expected to cooperate with Internal Investigations While the investigation is in progress take no action on the application in question or make any changes to an active case in question without consultation with the Internal Investigations Manager If a questionable customer situation exists and the worker is uncertain if a referral should be made consult with the supervisor andor Public Assistance Investigator The table below shows some guidelines in clarifying inconsistent information Process Action Ask the Right Questions Workers have the right to ask questions regarding the customers situation which pertain to eligibility for assistance If the information is not consistent with the previous case record information ask the customer why the information is not consistent If the customer refuses to clarify inconsistent information aid must not be issued or continued Gather Accurate Information It is the workers responsibility to gather accurate information If the customer cannot provide accurate information assist the customer Third party verification may be necessary in situations where the customer cannot provide accurate information Verify information before issuing assistance or before allowing assistance to continue Review Documentation Carefully All case documentation must be reviewed carefully for content and consistency Each form narrative entry and piece of case documentation must build the history of the customers situation All forms and NOAs must be dated and allow the reader of a case file to understand the customers situation Share Information Across Programs In situations where companion cases exist compare case information New information such as IEVS reports must be shared with a worker who has the other active case If information is not imaged for the companion case enter a case comment Sworn Statements In situations of abuse obtain a sworn statement form the victim or victims representative when the victim is not competent This sworn statement may be used as verification of abuse if it is determined that the person is credible and documents this in the case record 3 Allegation of Fraud Processing Guide 991132A shows the actions based on the type of allegation and how it is received County of San Diego Health and Human Services Agency HHSA Cash Assistance Program for Immigrants CAPI Program Guide Fraud Prevention and Detection Number Page 991132 3 of 3 Procedure Follow the actions in the policies above and Processing Guide 991132A for fraud prevention and detection in CAPI Program Impacts None References MPP 20000 and 20200 Sunset Date This policy will be reviewed for continuance on or by 10312022 Approval for Release Rick Wanne Director Eligibility Operations