4.06 Fraud

Fraud. A person commits fraud in Vermont if he or she: “[K]nowingly fails, by false statement, misrepresentation, impersonation, or other fraudulent means, to disclose a material fact used in making a determination as to the qualifications of that person to receive aid or benefits under a state or federally funded assistance program, or who knowingly fails to disclose a change in circumstances in order to obtain or continue to receive under a program aid or benefits to which he or she is not entitled or in an amount larger than that to which he or she is entitled, or who knowingly aids and abets another person in the commission of any such act . . . ;”71 or 71 33 VSA § 141(a). General Provisions and Definitions Part 1 – Page 22 (Sec.4.00, Sub.4.06) “[K]nowingly uses, transfers, acquires, traffics, alters, forges, or possesses, or who knowingly attempts to use, transfer, acquire, traffic, alter, forge, or possess, or who knowingly aids and abets another person in the use, transfer, acquisition, traffic, alteration, forgery, or possession of a . . . certificate of eligibility for medical services, or Medicaid identification card in a manner not authorized by law . . . .”72 Legal consequences. An individual who commits fraud may be prosecuted under Vermont law. If convicted, the individual may be fined or imprisoned or both. Action may also be taken to recover the value of benefits paid in error due to fraud. AHS’s responsibilities. An individual may report suspected fraud to AHS. When AHS suspects that fraud may have been committed, it will investigate the case. If appropriate, the case will be referred to the State’s Attorney or Attorney General for a decision on whether or not to prosecute. Suspected fraud. The following criteria will be used to evaluate cases of suspected fraud to determine whether they should be referred to a law enforcement agency: Does the act committed appear to be a deliberately fraudulent one? Was the omission or incorrect representation an error or result of the individual’s misunderstanding of eligibility requirements or the responsibility to provide information? Did the act result from AHS omission, neglect, or error in securing or recording information? Did the individual receive prior warning from a state employee that the same or similar conduct was improper? Examples The following are examples of instances in which fraud might be suspected and referral considered: (i) The individual accepts and continues paid employment without reporting such employment after having been clearly informed of the necessity of such notification. (ii) The individual fails to acknowledge or report income from pensions, Social Security, or relatives when it is reasonably clear that there was a willful attempt to conceal such income. (iii) The individual disposes of property (either real or personal) and attempts to conceal such disposal. (iv) The individual misrepresents a material fact, such as residency status or dependent relationship or status, in order to receive benefits to which they would not otherwise be eligible. These examples are intended as a guideline; each case will be evaluated individually. Methods of investigation. Any investigation of a case of suspected fraud is pursued with the same regard for 72 33 VSA § 141(b). General Provisions and Definitions Part 1 – Page 23 (Sec.4.00, Sub.4.07) confidentiality and protection of the legal and other rights of the individual as with a determination of eligibility. Review and documentation of investigation. Procedures will be established for review and documentation of a fraud investigation. Referral to Law Enforcement Agencies. The final decision regarding referral to a law enforcement agency shall be the responsibility of the appropriate department’s commissioner. 4.07 [Reserved] (01/15/2017, GCR 16-094)