County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Fraud Prevention and Referral Number Page 1601 1 of 6 Revision Date 412018 Background This section provides regulations regarding Fraud Prevention Early Fraud Prevention Referrals Other Fraud Referrals IEVS Other Fraud Prevention Systems The Income eligibility verification system IEVS was updated to include more nonwage income data from the Franchise Tax Board Fraud Definition Fraud exists when a person on behalf of himherself or others has Knowingly and with intent to deceive or defraud made a false statement or representations to obtain benefits obtain a continuance or increase of benefits or avoid a reduction of benefits Knowingly and with intent to defraud failed to disclose a fact which if disclosed could have resulted in a denial reduction or discontinuance of benefits Knowingly and with intent to deceive or defraud accepted benefits to which heshe was not entitled or accepted an amount of benefits knowing it is greater than the amount to which heshe is entitled Made statements which heshe knew to be untrue for the purpose of obtaining benefits continuing to obtain benefits or avoiding a reduction in benefits Policy A Reasonable Grounds to Suspect Fraud Reasonable grounds to suspect fraud may exist if the applicantrecipient Provides unclear conflicting or inconsistent information Has difficulty in 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 to DHCS Fraud Investigations MediCal 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 1602 C Fraud Prevention Responsibilities 1 Family Resource Center FRC Manager The FRC Manager ensures that staff conduct accurate eligibility determinations utilizing all automated information systems appropriate to the eligibility determination process County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Fraud Prevention and Referral Number Page 1601 2 of 6 2 Supervisors Worker supervisors review the availability and use of automated information systems with workers to ensure they utilize the available information 3 Worker Ensure that the applicantbeneficiary understands their responsibility for reporting anything that affects the determination of eligibility or shareofcost Review this information with the applicantbeneficiary at application and redetermination Ensure that the applicantbeneficiary understands the penalties for failing to report Document whether or not the individual showed understanding of their reporting responsibilities Take prompt action on any information received or circumstances which could affect eligibility or the SOC amount Obtain required verifications and review for consistency and completeness Attempt to resolve any inconsistent incomplete or seemingly altered verifications with the applicantbeneficiary Initiate a referral to DHCS investigators if there is inconsistent or questionable information that cannot be resolved D Early Fraud Detection Make prompt referrals to DHCS investigators when referrals are appropriate Procedures and required actions for making an Early Fraud Detection referral to DHCS are located in the Fraud Prevention Processing Guide DHCS investigators will attempt to respond within 15 calendar days depending on departmental needs and will grant higher priority to cases requiring short turnaround Referrals will be prioritized by DHCS in the event there is not enough staff to cover the existing referrals Granting eligibility may not be delayed pending the completion of an investigation as long as all inconsistent and conflictingquestionable information has been resolved E Full Field Investigation When inconsistent or questionable information is discovered on a case granted for more than 90 days it can be referred to DHCS Investigators for preliminary investigation The investigator will provide investigation findings and follow up with the worker on the referral and determine if a full field investigation is needed The full field investigation takes additional time F Solicitation Referrals Soliciting is the act of tempting or enticing someone to do wrong This includes advising MediCal applicants how to answer questions conceal information or provide false or fraudulent information in order to Establish eligibility to MediCal program benefits Obtain a greater MediCal program benefit Prepare for investigation of their circumstances by MediCal representatives including DHCS investigators County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Fraud Prevention and Referral Number Page 1601 3 of 6 G Fraud Hotline DHCS operates a tollfree hotline for reporting of possible MediCal fraud at 18008226222 Refer callers to this hotline for complaints of potential fraud on closed cases and noneligibility related fraud in MediCal provider or misuse of MediCal H Income Eligibility Verification System IEVS IEVS provides a computer match of applicantrecipient name date of birth and in some cases Social Security Number to the following information sources MEDSCentral Database CDB eligibility history file EDD wage employment and disability files Unemployment Insurance Benefits UIB and Disability Insurance Benefits DIB 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 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 SSAInternal Revenue Service IRS wage and selfemployment income information from the Benefit Earnings and Exchange Record BEER files IEVS is divided into two systems the applicant and the recipient system The applicant system provides information on applicants during the application process and the recipient system consists of the following subsystems Payment Verification System PVS New Hire Registry NHR Earnings Clearance which is also known as the Integrated Fraud Detection IFD Asset Match BEER More information about these subsystems is located in the Fraud Prevention Processing Guide I IEVS as Verification IEVS UIBDIB and RSDI match results may be used as verification of information supplied on the Statement of Facts J Other Fraud Prevention Systems Systematic Alien Verification for Entitlement SAVE The SAVE system compares US Citizenship and Immigration Services USCIS information with alien numbers entered in CalWIN Information from the primary SAVE system indicates if the client has legal immigration status MediCal Eligibility Determination System 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 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Fraud Prevention and Referral Number Page 1601 4 of 6 Eligibility Verification System main menu can be used to identify whether a client received CalWORKs CalFresh MediCal Covered CA andor Homeless Assistance within California Central Data Base CDB CDB is a statewide data base 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 whether the property actually exists This system can be used to determine if there is conflicting information Jail Clearance View to verify if an applicantbeneficiary or absent parent is in or out of jail 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 FRC upon posting Upon notification of the posting of the DJJ match report Step Action 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 Public Assistance Reporting Information System PARIS PARIS is a system that allows state and federal agencies to verify public assistance There are currently two reports that are issued by PARIS Interstate Match which allows states to compare their beneficiary information with other states Federal Match which allows states to compare their beneficiary information with the US Department of Defense and the US Office of Personnel Management Federal law requires that DHCS implement the interstate match To comply with this law DHCS developed a residence verification match DHCS runs the PARIS federal match quarterly It provides a list of beneficiaries receiving unreported federal income The income includes retirement payments received by former federal civilian and military employees and current military reservists The report will indicate in the record type column County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Fraud Prevention and Referral Number Page 1601 5 of 6 if the beneficiary is a retired military veteran code MR a reservist code MV or a retired civilian code CR Review the lists and follow the procedures in Processing Guide 19 Procedure Directions for the following procedures are located in the Fraud Prevention Processing Guide Referrals to DHCS Investigators Community Complaint Procedures Processing IEVS NHR ECSIFD Asset Match BEER reports Other Program Impacts CalWORKs CalWORKs Assistance Units AU may not be automatically discontinued for whereabouts unknown because they may still be eligible to CalWORKs if they are still residing in California Review the circumstances of the case and contact the AU to provide them with an opportunity to clarify the discrepancy 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 Attempt contact with the AU before making any referral for fraud investigation or taking action against the grant CalWORKs AUs are required to report any address changes to the worker within 10 calendar days CalFresh A timely NOA is not required for PAFS and NAFS 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 MEPM 21E3 ACWDLs 0941 1005 and 1114 MPG Letter 822 MEDIL 1725 County of San Diego Health and Human Services Agency HHSA MediCal Program Guide Fraud Prevention and Referral Number Page 1601 6 of 6 Sunset Date This policy will be reviewed for continuance by 4302021 Approval for Release Rick Wanne Director Eligibility Operations