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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 100 – General Provisions P a g e | 37 Effective Month: March 2019 Fraud is a serious charge to make, and the results can be serious. As a result, the facts in such a case must be clearly and accurately stated. The Mississippi courts have ruled, “There is a presumption against fraud, dishonesty and bad motive, and evidence to overcome this presumption must be more than mere preponderance; it must be clear and convincing. “ Although fraud is a question for courts to decide, the regional office must determine suspected fraud, i.e., whether there is a basis for belief that fraud may have been committed. In making this decision, the specialist must consider the individual’s intent, and the individual’s mental capacity. Also, a clear distinction, based on verified facts, must be made between misrepresentation with intent to defraud and mis-statements due to misunderstanding of requirements or of the individual’s responsibility to report information. It is also important to distinguish between suspected fraud and omission, neglect or error by regional office staff in helping the applicant or recipient to understand his responsibilities and in securing and recording pertinent information. An applicant or recipient may be suspected of fraud when the individual willfully and knowingly and with intent to deceive obtained Medicaid or CHIP by: ▪ Making a false statement or misrepresentation; or ▪ Failing to disclose a material fact; or ▪ Not reporting changes in income or other eligibility factors that affect the benefit; and ▪ As a result of the action or inaction, the individual obtains or continues to receive assistance. In other words, if the information had been known, it would have resulted in denial or reduction of benefits to the individual or would have resulted in a different amount of Medicaid Income.