803            FRAUD

The misrepresentation of fact or omission of information with the intent of illegally obtaining service, payment, or other gain constitutes fraud. Fraud exists when a recipient intentionally fails to comply with instructions to report income, resources, household composition or other factors which may affect eligibility for Medicaid, or intentionally fails to report changes in these circumstances.

Fraud also includes circumstances when a provider of medical services knowingly and willingly bills Medicaid for services not rendered.

Persons knowingly and willingly aiding a recipient or provider in committing fraud are considered to be aiding in the commission of the act and may also be held responsible.

803 A.    ELIGIBILITY TECHNICIAN RESPONSIBILITIES

If an interview is conducted for non-MAGIModified Adjusted Gross Income Medicaid programs, the ETEligibility Technician must advise all applicants of their rights and responsibilities relating to their receipt of assistance. A full explanation of the eligibility requirements, the need to complete the application, and report any changes in circumstances is essential so that a recipient may not later deny knowledge or understanding in a legal proceeding. Verification of all information in a recipient's case file may be critical evidence in a fraud case.

If an ETEligibility Technician suspects a recipient of fraud, the ETEligibility Technician should refer to the Administrative Procedures Manual section 112-4 for proper procedures.