Clarifying Information - WAC 388-446-0001

*** As a result of implementation of the Affordable Care Act (ACA), this clarifying page may no longer be effective for medical coverage applications received on or after 10/01/2013. Clients under 65 years of age who need to apply for medical coverage on or after 10/01/2013 should be referred to Washington Healthplanfinder. Applications for medical coverage for households where all members are 65 years of age and older should be referred to Washington Connection. ***

The FRAUD chapter is related to the BENEFIT ERRORS and the ADMINISTRATIVE HEARINGS chapters. An overpayment of benefits often comes before a referral to the court system or to an Administrative Disqualification Hearing for a determination of fraud.

Staff may make a referral for fraud investigation when they become aware of facts that indicate an overpayment has occurred as a result of a client's intent to conceal or misrepresent facts to the department. Potential fraud may also be discovered outside of the process of determining what caused the household to receive incorrect benefits.

Discovering Potential Fraud / Unlawful Activity: Discovery of possible fraudulent or unlawful practices may result from complaints or information received by the local office in a variety of ways. Examples include: Direct calls to the local office or customer service center; Welfare Fraud Hot Line Complaint (1-800-562-6906); Client change of circumstance report; ESD Quarterly Earnings Alert or Comparison Report; Fraud Early Detection Program (FRED) investigations. FRED investigations may be requested for active cases to establish ongoing eligibility. A Quality Assurance Review (QA).

Establishing an intentional cash overpayment: The Public Benefit Specialist (PBS) can establish an Intentional overpayment if the client received incorrect cash benefits and there is evidence in the case record showing intent. Intent means that the client knows what facts or changes to report, when to report those changes, had the opportunity to report, and chose not to report. Intent also implies that the client didn't report a change or a fact because they knew that reporting it would probably have a negative effect on their benefits.

The Office of Fraud and Accountability (OFA) Fraud Early Detection program (FRED): The Fraud Early Detection program (FRED) is under the direction of the Office of Fraud and Accountability and provides criminal investigators when activities are required that go beyond the scope of the Financial Service Specialist's authority. The purpose of FRED is to: Provide a cost-effective measure for reduction of errors; Save benefit funds for families requiring assistance; Reduce the need to investigate and prosecute recipients by resolving questionable circumstances prior to the authorization of benefits.

How FRED improves program integrity: FRED investigators help support program integrity in the following ways: Obtain information requested by the PBS; Use interviews with clients and third parties (called collateral contacts) to resolve questions or inconsistencies; Report findings to the PBS; Make recommendations regarding criminal prosecution; Participate in Administrative Hearings, as needed.

Referrals to OFA based on overpayments: After establishing an intentional cash overpayment, the case is referred to the Office of Fraud and Accountability (OFA) for possible prosecution. The client has the right to an Administrative Hearing over the establishment of the overpayment and the intentional designation. See BENEFIT ERRORS and ADMINISTRATIVE HEARINGS .

Establishing Intentional Program Violations for Food Assistance: When the overpayment involves food assistance, current policy states that only a court of law or an Administrative Disqualification Hearing can determine an Intentional Program Violation (IPV). The PBS establishes an unintentional overpayment, called Inadvertent Household Error, and refers, with any cash overpayment, to OFA for investigation and potential prosecution.

Threshold for Administrative Disqualification Hearing: If the food assistance overpayment, or separate instances of suspected IPV total more than $85 for current recipients or more than $125 for inactive households, we refer the case for an Administrative Disqualification Hearing, according to local office procedures. See ADMINISTRATIVE HEARINGS .