General On-Going Fraud Referral

Overview

General On-going Fraud Referrals to SIU are to be initiated through the CalWIN referral system as part of the EW's role in the prevention and detection of fraud.

The intent of the fraud referral process is to facilitate the prompt investigation and possible prosecution of public assistance fraud. Following the processes and procedures contained in this chapter helps ensure that:

  • Fraudulently obtained public assistance benefits are kept to an absolute minimum; and
  • The rights of the applicant/recipient are maintained.

Note: Eligibility determinations should not be delayed due to a pending investigation. If the household has complied with all necessary requirements benefits need to be approved timely.

[Refer to the Medi-Cal Handbook Chapter 49 - “Overpayment Overview,” page 49-20] for instructions when an EW discovers a Medi-Cal overpayment.

Prior to Referral

Prior to making a referral for General On-Going Fraud, the EW must review Pre-Referral Requirements, When to Refer, and Possible Criteria for FRED/General On-Going Fraud Referral. This will ensure that the referral is appropriate and that erroneous referrals, based solely on eligibility problems or administrative errors, are avoided.

Evaluation of Information

After the eligibility information has been gathered, reviewed and analyzed, the EW must make a number of determinations, based on the available data.

Some common determinations which must be made by the EW are:

  • Is the client eligible?
  • If the client is eligible, what is/was the correct amount of benefits?
  • If the client is ineligible or benefits were incorrect, was there an overpayment?
  • If an overpayment has occurred, can it be corrected by grant adjustment or repayment from liquid assets?
  • If an overpayment has occurred, are there reasonable grounds to suspect fraud?

To Refer: Yes or No

After the information is evaluated, a decision must be made as to whether there are reasonable grounds to suspect fraud.

IF... THEN...
There is a question as to whether or not there are reasonable grounds to suspect fraud, Consult with your supervisor, and refer, if appropriate.
There are reasonable grounds to suspect fraud,
  • Make an on-line referral via the CalWIN Client Referral subsystem.
    • Select from the Need drop-down table [Fraud - General Referral].
  • Document on the [Maintain Case Comments] window that a General Fraud Referral was initiated.
The suspected fraud has caused a Medi-Cal overpayment (including CalWORKs cases which also result in Medi-Cal ineligibility) Refer to Medi-Cal Handbook, “Overpayment Referral Procedures,” page 49-33 for more information.

Related Topics

Fraud - General Information