112-4          REFERRAL OF SUSPECTED FRAUD CASES

Note:  

Caseworkers should not refer cases for investigation simply because they have been unable to obtain verification needed to process the case.  Follow instructions in the program’s policy manual or seek the assistance of a supervisor when the client cannot or fails to provide needed verification.

112-4 A.     EARLY FRAUD DETECTION REFERRALS

Early Fraud Detection (EFD Early Fraud Detection) is the investigation of potentially fraudulent applicants and clients to prevent their fraudulent entry into the Food Stamp or Alaska Temporary Assistance programs.  Early Fraud Detection referrals are limited to:

• Anchorage, Kenai Peninsula, Fairbanks, the Mat-Su Valley, and Southeast Alaska areas;
   

• Intake applications, re-certification applications, TA Temporary Assistance reviews, and add-on applications; and
   

• Cases referred within the first four months from the date of application, re-certification, reapplication, or TA Temporary Assistance review.

Case workers finding inconsistencies or discrepancies in information obtained from the client or collateral contacts during the application process should refer the case by completing the Early Fraud Detection Referral form (GEN 97a) accessible from the DPA Division of Public Assistance eForms website.

Example:  

A collateral contact states the applicant has two children living with her, but the applicant's landlord states that only one child is in the home, and the client applied for three children.  Refer this case for an EFD Early Fraud Detection investigation due to the discrepancy in the number of children reported in the home.

1. Completing an Early Fraud Detection Referral: GEN 97A

The eForm fields on the GEN 97a can be accessed by "tabbing" to the fields or by placing the cursor at the beginning of the field that you want to enter the data in.  The form collects basic information on the Primary Information Person (PI Primary Information Person) and the following information needed by the fraud investigator:

Map in File?  Check "yes" by clicking on the box if you have a map to the location of the residence, or click on the ”no” box if you do not have a map then tab to the "Directions to Home"  field and enter the directions to the home provided by the client

School Hours:  Provide the school hours for children in the household during the school year

Work Hours:  If the adults in the household are employed, provide the known work hours

APP Type:  Indicate what type of application and what programs the client applied for and whether it is a NEW, ADD-ON, or a RECERTIFICATION for each program type listed

Briefly describe discrepancies:  Explain the discrepancies encountered in processing the case.  Provide as much specific information as possible related to the allegations.  Include full names, Social Security Numbers, and birth dates.

Note:  

A GEN 97 must document the reason the caseworker suspects fraud in order for an investigator to make an unscheduled home visit.

Special notes:  

This field is for information you think the investigator should know, such as a client with a history of violence, or substance abuse issues, or any other information that could be helpful to the investigation.

After the eForm is complete press the "Email this form to Fraud" button located at the bottom of the form.  The form will automatically open your Outlook "New Mail Message" dialog box.  The "To:" field should already display the e-mail address of Fraud_Allegations@alaska.gov.

IMPORTANT:  

In the "Subject" field of the new e-mail message, use the following format:  enter the type of referral, in the case EFD Early Fraud Detection (early fraud detection), client’s last name, first name and DPA Division of Public Assistance case number.

Be sure to print a copy for the eligibility case file and after you e-mail the eForm to the Fraud Control Unit (FCU Fraud Control Unit) you must clear the eForm by using the "clear" button at the bottom of the form.  Once this is done the data is gone.  The FCU Fraud Control Unit will assign the case right away and the investigation should be completed within seven days.  Some delays may occur depending on the circumstances of the case.

2. Completing the Early Fraud Findings Report:  GEN 97b1

The Fraud Control Unit investigator reviews the referral submitted by the caseworker on the GEN 97a eForm.  The investigator may conduct a field visit, and investigate as necessary to resolve the discrepancies.  Within seven days of receiving the GEN 97a form, the investigator sends the Early Fraud Findings Report eForm (GEN 97b1) to the referring caseworker by e-mail.  Some delays may occur depending on the circumstances of the case.

The eForm fields on the GEN 97b1 can be accessed by "tabbing" to the fields or by placing the cursor at the beginning of the field that you want to enter the data in.  The form collects basic information on the caseworker who made the referral, and the following information specific to the Fraud Investigator’s findings:

Case #:  Enter the DPA Division of Public Assistance/EIS Eligibility Information System case number.

Case Name:  Enter the PI Primary Information Person’s name on the case;

Fraud Case #:  Enter the assigned Fraud case number.

Report of Findings:  Place a check mark in the box by clicking on the any of the following:  Residence, HH House Hold Composition, Number of Parents in HH House Hold, Resources, Income-Earned/Unearned/Self-Empl., or check the Other box.  Check all boxes that apply.

Briefly describe findings:  In the text field below the "Instructions" explain what you found and cite supporting evidence to substantiate the reported findings as related to the caseworker’s suspected incidents of fraud.  If more space is needed, continue on page 2 of the eForm in the section titled "Report of Findings CONTINUED."

After completing the eForm, press the "Email Caseworker" button located at the bottom of the form.  The form will automatically open your Outlook "New Mail Message" dialog box.  Click on the "To" button and the Global Address List will display.  Select the name of the referring caseworker so their name appears in the "To" field.

IMPORTANT:  

In the "Subject" field of the new e-mail message, use the following format:  enter the type of referral, in this case EFD Early Fraud Detection (early fraud detection), client’s last name, first name and DPA Division of Public Assistance case number.

Be sure to print a copy for the investigation case file after you e-mail the eForm to the caseworker.  You must clear the eForm by using the "clear" button at the bottom of the form.  Once this is done the data is gone.

3. Completing the Action Taken As A Result of EFD Early Fraud Detection Findings: GEN 97b2

After considering the investigator’s findings and making an eligibility determination on the application, the caseworker notifies the Fraud Control Unit of benefit changes, if any, resulting from the investigation using the eForm GEN 97b2.

The eForm fields on the GEN 97b2 can be accessed by "tabbing" to the fields or by placing the cursor at the beginning of the field that you want to enter the data in.  The form collects basic information on the caseworker who received the investigator’s findings, and the following information specific to the Fraud Investigator’s findings, and specifically describes actions taken as a result:

Case #:  Enter the DPA Division of Public Assistance case number

Fraud Case #: This is the number that the Fraud Control Unit has assigned for the investigation.  This number is identified on the GEN 97b1.

Action Taken on EFD Early Fraud Detection Findings: Check the appropriate box for whatever action you took as a result of the investigator’s findings.  Check the program boxes that apply.

Print a copy for the eligibility case file.

E-Mail the form to: Fraud_Allegations@alaska.gov.  This e-mail address should be in the "To:" section of the e-mail automatically when you click on the Email button at the bottom of the form.  Remember to "clear" the form once you have printed and sent a copy to the Fraud Control Unit.

112-4 B.     POST CERTIFICATION INVESTIGATION

Post Certification Investigation (PCI Post Certification Investigation) referrals can involve suspected applicant or recipient fraud, and investigations are available statewide.

When To Refer A Case

The case should be referred directly to the Fraud Control Unit when a caseworker or QA Quality Assurance reviewer is certain or highly suspects a recipient has intentionally broken program rules.

Note:

Caseworkers should try to resolve questionable fraud issues before referring the case to the Fraud Control Unit.

How To Make A Referral

Allegations of public assistance fraud come from many sources, including DPA Division of Public Assistance employees, legislators, other departments, and the general public.  The status of the client’s case determines what action the Fraud Control Unit takes.

If the Fraud Control Unit receives an allegation from outside DPA Division of Public Assistance on an open case or closed case, the FCU Fraud Control Unit worker records the allegation on a Fraud Allegation Report form (FCU Fraud Control Unit 30) and forwards or e-mails it to the assigned caseworker.

The caseworker discusses the case with his or her immediate supervisor prior to making a post certification investigation referral.  Once a decision is made to refer the case to the Fraud Control Unit, the caseworker will complete the Fraud Complaint Report (GEN 40 Client Fraud Complaint Report).  The Fraud Complaint Report collects basic information on the referring caseworker and on the Primary Information Person (PI Primary Information Person).  The caseworker includes information specific to the fraud allegation as follows:

The caseworker forwards to the Fraud Control Unit by fax, or scans and e-mails, any documentation that can substantiate the fraud allegation.

Send the completed Fraud Complaint Report to the Fraud Control Unit in the Anchorage by clicking on the Email to Fraud Button.  The accompanying documents or attachments that are not e-mailed or faxed (fax 907-269-1062) can be mailed to:

Program Integrity and Analysis Section

Fraud Control Unit

3601 C Street, Suite 200

Anchorage, AK   99503

IMPORTANT:  

In the "Subject" field of the new e-mail message, use the following format: enter the type of referral, in the case PCI Post Certification Investigation (post certification investigation), client’s last name, first name and DPA Division of Public Assistance case number.

Action On Referrals

The Fraud Control Unit screens the referrals to identify the issues, and enters the information on the Fraud Case Management system for tracking purposes.  A staff member in the Fraud Control Unit researches policy issues before assigning the case to an investigator.

The Fraud Investigator reviews both the fraud allegation and the client's case file to determine what clear and convincing evidence is needed to prove fraud has occurred.  The fraud investigator contacts employers, landlords, schools, agencies, clients, and other necessary sources to obtain the needed evidence.  Field visits are regularly conducted as an integral part of the investigation.

1. When the investigator finds fraud did occur the case is referred to the unit's Fraud Loss caseworker, who completes the Fraud Loss Statement form (FCU Fraud Control Unit 50) indicating specific months of loss and the exact amount of fraudulent overpayment for each program.  The case is then prepared for an Administrative Disqualification Hearing or criminal prosecution.
    

2. If evidence gathered during the investigation indicates fraud did not occur, the investigator completes a Fraud Complaint Disposition and Summary of Investigative Findings form, explaining the rationale for the finding.
   
   If the case is open, this report is sent to the caseworker currently assigned to the case.  It is this caseworker’s responsibility to determine if a client-caused overpayment occurred.  If so, the worker completes a Claim Determination form (GEN 95) and sends it to the Claims Unit.  Refer to Chapter 111 for information on claims.
   
   If the case is closed, this report is sent to the worker who made the referral.  A copy is placed in the eligibility case file.  It is the Fraud Control Unit’s responsibility to determine if a client-caused overpayment occurred.  If so, the Fraud Loss caseworker prepares and submits the Claim Determination form (GEN 95) to the Claims Unit.
    

3. Occasionally, the unit receives a Fraud Complaint Report about an issue that does not meet the definition of fraud.  When this occurs the referral is given to the Fraud Control Unit Manager who will send an explanation of why the allegation does not meet the definition of fraud back to the referring worker.

112-4 C.     FRAUD REFERRALS FROM QUALITY ASSESSMENT

The Quality Assessment Unit can refer cases directly to the Fraud Control Unit when the reviewer finds evidence in the course of the quality control review that the recipient provided false information or intentionally withheld affecting their eligibility.