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MEDICAL SERVICES POLICY MANUAL,SECTION N N-100 Fraud Investigation N 110 Functions

N-100 Fraud Investigation

MS Manual 01/01/14 The Fraud Investigations Unit identifies, investigates, and refers for prosecution any individual accused of committing Theft of Property or Theft of Public Benefits as defined by state law. This includes Agency staff, recipients or other persons who deliberately violate the rules and regulations of DHS to defraud the state. Fraud Investigations prepares the Administrative Disqualification File on persons accused of committing an intentional program violation. The Fraud Investigations Unit is organizationally located within the Office of Quality Assurance.

N-110 Functions MS Manual 01/01/14 The Fraud Investigations Unit has the following major functions: • Review the case record and independently verify information contained in the file to determine if a criminal investigation is warranted. • Investigate to gather evidence in cases where there is a probability that a fraudulent act was committed. • Refer to the prosecutor if facts are obtained which indicate that the accused person, by deception, received DHS monies/benefits to which he/she was not entitled.

N-120 Referral Sources MS Manual 01/01/14 Reports of suspected fraud may be received from any source within the Department of Human Services, the general public, public officials or other public agencies, or by the Fraud Investigations Unit, itself.

N-130 Reporting Suspected Fraud MS Manual 01/01/14 Criteria for reporting suspected fraud: • The suspected fraudulent act(s) resulted in a cumulative overpayment of $200 or more. • Cases in which the client is receiving assistance in two or more names, counties or states.