Family and Children's Medicaid MA-3535 RECIPIENT FRAUD AND ABUSE POLICY AND PROCEDURES
IV. FRAUD VS. MISREPRESENTATION
Although fraud is a question for the courts to determine, the county dss must determine whether there is a basis for belief that fraud may have been committed. In making this decision, intent and the mental competency of the individual must be considered. Also, a clear distinction, based on verified facts, must be made between misrepresentation with intent to defraud and misstatements due to the misunderstanding of eligibility requirements or of the responsibility for providing the county dss with information.
It is also important to distinguish between intent to defraud and omission, neglect, or error by the county dss in helping a recipient to understand his responsibilities and in securing and recording pertinent information.
B. Fraud vs. Misrepresentation
Fraud is, by law, a crime against society that can only be determined in a criminal court. It is the willful and intentional act that creates the crime, rather than the resulting overpayment.
a. For Medicaid purposes the following definition of “client” applies throughout this policy.
Client – The recipient, parents and/or financially responsible adults of a minor child, legal spouse of a recipient, or a representative acting in behalf of a recipient. They may all be debtors except a minor child.
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Misrepresentation causes monetary loss as a result of a client’s action or inaction. Misrepresentation can be intentional or unintentional.
a. Intentional misrepresentation - The client gives incorrect or misleading information in response to either oral or written questions. The information is provided with the knowledge that it is incorrect, misleading or incomplete. This is suspected fraud until decided by a court of law. If the courts so decide, the claim should be changed in EPICS to an Intentional Program Violation (IPV). Document the change on the EPICS Notepad.
b. Unintentional misrepresentation - There is no proof that the client acted willfully and intentionally to obtain more benefits than those to which he was entitled. The client gives incomplete, incorrect or misleading information because he does not understand the eligibility requirements or his responsibilities to provide the county dss with required information. This would be shown in EPICS as an Inadvertent Household Error (IHE).
3. Criteria for Fraud
To have a cause for action for fraud in public assistance cases, there must be proof of a statement made by the client, and the following conditions must be found with regard to such statement:
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a. The statement is false; and
b. The client knows that the statement is false, or the client makes the statement recklessly and with knowledge of the truth or falsity of the statement; and
c. The statement is made by the client, with the intent that it will be relied on by the county dss, and that it will induce the county dss to authorize assistance to which the recipient is not entitled or to assistance greater than that to which the recipient is entitled; and
d. The county dss does in fact rely upon the statement given by the client, and awards assistance to which the recipient is not entitled or assistance greater than that to the recipient is entitled; and
e. The county dss has informed the client, of the law relating to fraud and appropriate information has been entered in the agency record; and
f. The client has signed a statement that all information given by the recipient and/or his representative pertaining to his eligibility is correct and true to the best of his knowledge.