E. PAF INVESTIGATION FINDINGS/FRAUD HOTLINE

 

Completed Investigations

Upon receipt of findings from the investigator, the Human Services Specialist (HSS) must make the eligibility/benefits amount determination based on the findings, the information provided by the applicant/recipient, and existing rules and regulations of the program. For EFD/P referrals, the HSS must respond to the PAF report by indicating the disposition of/action taken on the case and the dollar savings in FRTS.

 

Fraud Exists  

 

If it is determined that fraud exists, the HSS must promptly take appropriate case action, following timely notice requirements, to deny, reduce, or terminate benefits to which the applicant/recipient is not entitled. 

 

Applicant/recipient Rebuts Investigation Findings

 

Should the applicant/recipient present additional information and/or verifications to rebut the investigator's findings, the information/verifications must be reviewed for consistencies.  Although PAF agreement is not required, the HSS is to inform the PAF investigator of additional information and/or verifications received.  Generally, a sworn statement will not be considered acceptable to rebut the investigator's findings.  The decision to accept a sworn statement without other verifications MUST be made at the Assistant FRC Manager level.  All information must be thoroughly documented by the HSS in the case narrative.

 

HSS Questions Regarding the Investigation

 

If the HSS has questions regarding the investigator’s response, the HSS will discuss the issues with his/her SHSS.  

 

Over 90 Days

 

No referral sent to Full Field will be held by PAF for over 90 days.  Following the 90-day period, unassigned referrals will be returned to the HSS.  If the HSS has or later receives new or additional information concerning the fraud allegation, a new fraud referral with attachments is to be initiated on FRTS. 

 

 

Allegations Received Thought Fraud Hotline

The Public Assistance Fraud Division of the District Attorney Office has a Fraud Hotline to receive fraud allegations from the public.  This hotline receives many allegations each month.  Referrals from the Fraud Hotline are forwarded, by pending them in FRTS, to the HSS of record on active, pending or discontinued cases. 

 

If the case is pending to a preapplication number, the referral will be forwarded to a regular Intake HSS when one is assigned.  A Fraud Hotline referral on a closed case will be processed by PAF. (Allegations received during the month when the case is being closed will still be referred to the HSS of record.) 

 

 

Fraud Hotline HSS Actions

The following are actions to be taken by a FRC HSS upon receipt of fraud allegations through the Fraud Hotline:

1.    When the FRC HSS receives a FRTS printout indicating that a referral has been pended by the Fraud Hotline, he/she must review the information prior to transmitting the referral to PAF. (For example, an allegation that the absent parent is in the home or that the applicant/recipient has unreported income may already be known factors to the HSS.)

 

·        If this is known information (i.e., documented in the case) and eligibility and benefit level reflect this information.

·        If the information is not known, contact the applicant/recipient and question him/her about the information received.

 

2. If the information was not known and remains questionable after contacting the applicant/recipient, the HSS will update FRTS to refer the case to PAF.

 

3.  If the information was known and processed on the case, the HSS will update FRTS indicating the referral is resolved and complete a narrative entry in the “Additional Comments” section.

 

 

PAF Resolved Referral Procedures

FRTS revisions necessary for communication purposes went beyond the capacity that the system was designed for, requiring manual correspondence procedures to be implemented. To complete the process, PAF developed the Resolved Referral Correspondences form PAF/RRC-1.  This form is used by the PAF to request attachments or for clarification from the HSS worker once they resolve the referral.  PAF also utilizes the form to ask the worker the status on an overdue (after 90 days is considered over due) referral.  

 

 

Previous Referral on a Pending Case

If…

Then…

A referral was previously made on the case pending the result of the investigation,

Appropriate entry must be made FRTS with an indication in the "Additional Comments" section that a referral has previously been made under what tracking number. This will avoid duplicate referrals or letting the referral pended by Fraud Hotline to remain pending indefinitely. 

 

There is any new information from the allegation, which was not included in the previous referral,

It has to be forwarded to PAF by entering the information in the "Additional Comments" section of FRTS and using the previous referral's tracking number.

 

the HSS determines that the allegation should be investigated by PAF, and if there is no referral pending on the case,

The HSS must explain what actions have been taken to resolve the complaint/ allegation, prior to forwarding it to PAF, in the "Additional Comments" section of FRTS and promptly forward copies of necessary attachments. 

 

 

Reminder:  Any referral initiated by Fraud Hotline has a pending status on FRTS.  It is the FRC HSS's responsibility to indicate its disposition in FRTS to avoid an indefinite pending status and/or duplicate referrals.

 

 

Allegations Received by FRC’s

When a fraud allegation is received directly by the FRC, the person who is receiving the allegation will document the name and address of the person making the allegation (if he/she is willing to provide this information), case identifying information and content of the allegation.  The documentation of the allegation will then be given to the FRC administration for assignment. 

 

Generally, any allegation of fraud will be investigated by the HSS of record to the fullest extent possible for resolution and fully documented in the case narrative.  If an HSS has information about a case that is assigned to another HSS, he/she should not access that case.  The information should be given to the FRC management.  Unresolved allegations shall be referred to PAF for investigations.

 

 

Fraud Complaints on Closed Cases

Complaints or information received indicating possible fraud on closed cases in Record Library is to be referred to the Fraud Hotline.

 

 

Questionable Situations

When a questionable situation arises, and the HSS is unsure whether a fraud referral is warranted, the HSS should consult with his/her supervisor.  The EFD/P Investigator assigned to the FRC may be contacted when it involves an EFD/P referral.  For issues on Full Field referrals, the Full Field Supervisor who is the liaison for their FRC may be contacted.