11230 Fraud Referral

Before a referral to the Office of the Medicaid Inspector General (OMIG) for prosecution of suspected fraud can be made, it is necessary for the agency to first determine the amount (if any) of the alleged fraudulent overstated eligibility by following the procedures outlined in 11124 . The same act of alleged fraud repeated over a period of time shall not be separated so that separate penalties can be imposed. If it is decided that a case will not be prosecuted for fraud, then the overstated eligibility shall be handled as a client error as outlined in 11121.2 . The burden of proving fraud is on the agency. All referrals shall be reviewed by the Eligibility Supervisor and Program Integrity Specialist prior to the referral being sent to OMIG.

There is no minimum amount of alleged fraudulent overstated eligibility required to initiate a fraud referral.