County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG Fraud Prevention and Referral Number Page 901705 1 of 3 Revision Date April 1 2020 A BackgroundThis section shows the fraud prevention and referral procedures for the General Relief GR Program PurposeThis section has been reformatted to current format Some information moved to Desk Aids and procedures moved to Processing Guides B PolicyFraud prevention and identification is a primary goal of the Health and Human Services Agency HHSA Customers who change their statements regarding their current situation must clarify the information to establish eligibility It is the Human Services Specialists HSS responsibility to ensure that all information in the case file is consistent and conflicting information is clarified Lack of clarification is cause for case denial or discontinuance If conflicting information exists it must be corrected or clarified by the customer or make a referral to the Bureau of Public Assistance Investigations BPAI C Definition of Fraud Fraud exists when a person on their own or on behalf of others has knowingly and with intent to deceive or defraud Made a false statement or representation to obtain benefits obtain a continuance or increase in benefits or avoid a reduction of benefits Failed to disclose a fact which if disclosed could have resulted in a denial discontinuance or reduction of benefits Made statements which they knew to be untrue for the purpose of obtaining benefits continuing to obtain benefits or avoiding a reduction of benefits Accepted benefits to which they were not entitled or accepted an amount of benefits knowing it was greater than the amount to which they were entitled Note Situations where a person refused to return benefits mistakenly issued to them by the County or to sign a timely notice waiver for benefit reductiontermination are not considered fraudulent even though an overpayment may be caused by such a refusal D HSS Role in Fraud PreventionDetectionReferralHSSs are responsible for issuing GR 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 clarify inconsistencies before issuing benefits Make every effort to ensure that the customer understands their responsibilities to provide truthful information and to report within five days any changes that may affect their eligibility andor grant amount Additionally the customer must understand the penalties for failing to report truthfully and promptly Review these responsibilities with the customer at each application and redetermination Furthermore document in the case record to reflect if the customer appeared to understand these responsibilities County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG Fraud Prevention and Referral Number Page 901705 2 of 3 Obtain all mandated verifications 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 Document all contacts responses from the customer and any additional information received because of contacts fully in the case record If the inconsistent or questionable information still cannot be resolved after contacting the customer initiate a fraud referral If a questionable customer situation exists and the HSS is uncertain if a referral is appropriate consult with the supervisor andor BPAI investigator assigned to the Family Resource Center FRC Desk Aid 901705A shows the HSS responsibilities in preventing or detecting fraud E Suspicion of Employee FraudElevate information indicating that HHSA employees may have assisted customers to commit fraud or have committed fraud themselves immediately to HHSAs Internal Investigations Section All staff are expected to cooperate with the Internal Investigation Section While the investigation is in progress HSSs will take no action on the application in question or make any changes to an active case in question without consultation with the Internal Investigation Manager F Allegation of FraudProcessing Guide 901705A shows the actions for allegations of fraud G Early Fraud DetectionPrevention EFDP or Full Field ReferralsThe table below shows the purpose of these two types of referrals Referral Action EFDP The intent of EFDP is to have the investigator complete the investigation before an Referral application is granted to prevent the issuance of aid to a deceptive applicant or to terminate fraudulently obtained benefits shortly after granting Send a referral to BPAI when one of the following conditions are met The application date is less than 90 days old An allegationsuspicion derived directly from the redetermination process for example information obtained from the redetermination is in conflict with information in the case record and the recipient is unable to provide a satisfactory explanation and referral made as soon as possible following the redetermination process The case is a GR case In general the goal of BPAI is to complete the EFDP investigation within three to five workdays Full Field Only make full field referrals if recommended by BPAI Referral H Referral Process Processing Guide 901705B shows the referral process County of San Diego Health and Human Services Agency HHSA General Relief Program Guide GRPG Fraud Prevention and Referral Number Page 901705 3 of 3 I Referral Information Desk Aid 901705B shows the information that must be provided to BPAI to support the referral J Referral Returns from BPAI Desk Aid 901705C shows the common reasons for referral returns and the actions that can be taken to prevent returns Procedure Follow the actions in the policies above and the Processing Guides for fraud prevention and referral Other Program ImpactsNone References County Policy Sunset Date This policy will be reviewed for continuance by March 31 2024 Approval for Release Rick Wanne Director Eligibility Operations