County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Fraud Prevention and Referral Number Page 1601 1 of 5 Revision Date 06012021 BackgroundFraud exists when a person on behalf of themselves or others knowingly intends to deceive or defraud by Making a false statement or representations to obtain continue increase or avoid reduction of benefits Failing to disclose facts which if disclosed may result in a denial reduction or discontinuance of benefits Accepting benefits to which they are not entitled This section provides regulations on Fraud Prevention Early Fraud Referrals Income Eligibility Verification System IEVS Other Fraud Prevention Systems PurposeThe Asset Verification Program AVP was added to the section under IEVS In addition material on the Public Assistance Reporting Information System PARIS was updated to include recent program clarifications PolicyA Reasonable Grounds to Suspect FraudReasonable grounds to suspect fraud may exist if the customer Provides unclear or conflicting information Has difficulty with obtaining verifications or provides third party contacts that do not cooperate Presents documentation that appears to have been altered Additional fraud indicators can be found in Desk Aid 40 Potential Fraud Indicators B When to Refer for Fraud InvestigationMediCal fraud investigations are conducted by the Department of Health Care Services DHCS Investigators Fraud Referrals to DHCS investigators are made in the following situations At intake for early fraud detection Full field investigations for cases granted more than 90 days Solicitation referrals Potential overpayment period evaluations see MPG 1602 C Fraud Prevention Responsibilities Review the customers responsibility for reporting changes that affect eligibility or share of cost SOC at application and redetermination Ensure the customer understands the penalties for failing to report County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Fraud Prevention and Referral Number Page 1601 2 of 5 Note in case comments whether the customer shows understanding of their reporting responsibilities Take prompt action on any information or circumstances that could affect eligibility or SOC Obtain required verifications and review for consistency and completeness Attempt to resolve inconsistentincomplete information or seemingly altered verifications with the customer Initiate a referral to DHCS investigators when there is questionable information that cannot be resolved and may affect eligibility D Early Fraud Detection Make prompt referrals to DHCS investigators when appropriate following the procedures in Processing Guide 19 DHCS investigators will attempt to respond within 15 calendar days granting higher priority to cases requiring a short turnaround Eligibility must be granted if inconsistencies are resolved prior to the completion of the investigation E Full Field Investigation When inconsistent or questionable information is discovered on a case that has been active for more than 90 days it should be referred to DHCS Investigators for a preliminary review The investigator will provide referral findings to the Human Services Specialist HSS and indicate if a full field investigation is needed The full field investigation will take additional time and the case must remain active until the investigation is complete F Fraud Hotline DHCS operates a tollfree hotline for reporting possible MediCal fraud at 18008226222 Refer callers to this hotline for complaints of potential fraud on closed cases or information not related to eligibility provider or misuse of benefits G Income Eligibility Verification System IEVSIEVS provides a computer match of customer name date of birth and in some cases Social Security Number SSN to the following information sources MediCal Eligibility Data System MEDS Central Database eligibility history file MEDS AVP database Employment Development Department EDD wage employment and disability files Unemployment Insurance Benefits UIB and State Disability Insurance SDI Franchise Tax Board FTB interest and dividend information mortgage interest acquisition or abandonment of secured property broker or barter exchange proceeds certain government payments distributions from pensions annuities retirement plans real estate transaction proceeds Individual Retirement Account IRA contributions miscellaneous income original issue discount taxable distributions from cooperatives gambling winnings Retirement Survivors and Disability Insurance RSDI benefit information from Social Security Administration SSA files County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Fraud Prevention and Referral Number Page 1601 3 of 5 SSAInternal Revenue Service IRS wage and selfemployment income information from the Benefit Earnings and Exchange Record BEER files IEVS is divided into two systems Applicant and Recipient The Applicant system provides information on customers during the application process The Recipient system consists of the following subsystems Payment Verification System PVS New Hire Registry NHR AVP Earnings Clearance which is also known as the Integrated Fraud Detection IFD Asset Match BEER IEVS as Verification IEVS UIBDIB and RSDI match results may be used as verification of information that is provided on the Statement of Facts H Other Fraud Prevention SystemsPublic Assistance Reporting Information System PARIS PARIS is an information sharing system that allows state and federal agencies to verify customers circumstances PARIS currently issues two reports 1 Interstate Match Enables states to compare information with other states and provides a list of customers who are receiving selfsufficiency services in another state 2 Federal Match Enables states to compare information with the United States Department of Defense and United States Office of Personnel Management The report provides a list of customers who are receiving unreported federal income The income includes retirement payments received by former federal civilian and military employees and current military reservists The report indicates in the Record Type column if the customer is retired military veteran code MR a reservist code MV or a retired civilian code CR DHCS Residency Verification Program RVP The DHCS RVP conducts periodic data matching to detect if customers are living outside of California There are numerous detection sources such as information from the Department of Defense SSA the Medicare program and public records Note DHCS provides the PARIS and RVP reports quarterly to MediCal Program Review the reports and follow the procedures in Processing Guide 19 Systematic Alien Verification for Entitlement SAVE The SAVE system compares United States Citizenship and Immigration Services USCIS information with alien numbers in CalWIN Information from the primary SAVE system indicates if the customer has legal immigration status County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Fraud Prevention and Referral Number Page 1601 4 of 5 MEDS MEDS identifies all beneficiaries who receive MediCal in California MEDS is helpful in preventing and identifying duplicate aid cases The Known to Welfare screen on MEDS under the Income and Eligibility Verification System main menu can be used to identify if a customer received CalWORKs CalFresh MediCal Covered CA andor Homeless Assistance within California Central Data Base CDB CDB is a statewide database which is available to verify current and historical receipt of CalFresh benefits in California AssessorSecured Property This system allows workers to determine the owner of a property parcel the assessed value of the property and if the property exists This system can be used to determine if there is conflicting information Recorders Marriage and Death Index View to verify a marriage or death records Division of Juvenile Justice DJJ Match Reports DJJ reports are created by comparing a list of MediCal beneficiaries to a list of incarcerated juveniles and are sent to the County monthly by DHCS and posted to SharePoint with notification to the Family Resource Center FRC upon posting When notified that the DJJ match report has been posted take the following actions 1 Review the match report to ensure the correct case data was used 2 Resolve discrepancies with the beneficiary per procedures in Article 4 Section 8 3 Narrate actions and send appropriate notifications 4 Complete the TO BE FILLED OUT BY CWD fields on the match report fully explaining actions taken and forward to FRC designee for rollup and email to MediCal program NOTE Suspend eligibility of incarcerated juveniles if they meet the criteria in MPG 060502 Procedure MediCal Processing Guide 19 contains instructions on the following procedures Referrals to DHCS Investigators Community Complaint Procedures Processing IEVS NHR ECSIFD AVP BEER reports DHCS Residency Verification Programs PARIS Interstate Match RVP PARIS Federal Match Identifying Unreported Federal Income County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Fraud Prevention and Referral Number Page 1601 5 of 5 Other Program ImpactsCalWORKs If a CalWORKs recipient was discontinued on MEDS as part of the PARIS program complete a review of the case and make every effort to contact the recipient to determine residence Residence in the state but not in the county is a requirement for continued eligibility to CalWORKs CalFresh A timely Notice of Action NOA is not required for Public Assistance CalFresh PACF and NonAssistance CalFresh NACF households if it is determined based on reliable information from the PARIS program that the household is not residing in the state of California Discontinue the household at the end of the month in which the change was found The correct notice for Loss of Residence must be sent to the household All case actions must be recorded in Case Comments in CalWIN References MEPM 21M1 21M8 21E3 ACWDLs 0941 1005 1114 1718 MEDILs 1725 1737 2103 Sunset Date This policy will be reviewed for continuance by 05312024 Approval for Release Rick Wanne Director SelfSufficiency Services