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Report Alleged Fraud to Program Administrator

Policy: 

F/EA notifies Program Administrator in writing within ten calendar days of suspecting a potentially fraudulent situation as defined under 42 CFR 455.2. In addition to F/EA suspecting fraud, F/EA will notify Program Administrator in writing upon receiving a report of alleged fraud from a Counselor, participant, worker or other stakeholder. 

F/EA cooperates fully with the Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU).   F/EA makes every effort to provide any requested information and documentation within 3 business days of request. 
 
F/EA maintains confidentiality of any investigations performed by Program Administrator, MFCU or other agency.
Procedure: 

  1. F/EA <<Staff Title>> (or assigned staff) completes a fraud report form under the following circumstances:
    • F/EA staff suspect fraud as defined under 42 CFR 455.2
    • A Counselor reports fraud or submits a form to F/EA
    • A participant, workers or other stakeholder reports fraud to F/EA either via phone, in writing or in person
  2. When fraud is suspected or reported, record issue in Customer Service System
  3. Collect and log all applicable information including:
  • Who is reporting suspected fraud
  • Description of suspected fraud
  • Parties involved with suspected fraud
  • When suspected fraud occurred
  • Where suspected fraud occurred

 4.  Open applicable fraud report form from <<File Path>>

 5.  Complete fraud report form with applicable information

 6.  In “Subject” check the box for the person that is suspected of fraud

 7.  In Consumer Information section, enter all applicable information for participant

 8.  Obtain participant demographic information from Payroll System

 9.  Obtain Individual Budget information from Payroll System

10. If workers is checked under Subject, enter applicable workers information

11. Worker information can be obtained from Payroll System

12. In Complainant section, enter all information pertaining to person who reported suspected fraud

13. Data can be obtained from entry made for issue in Customer Service System

14. Answer each of the three questions listed on the bottom of the form

15. <<Staff Title>> (or assigned staff) completes Person Completing This Report Section

16. For whatever period reported in the allegation, <<Staff Title>> runs report of participant's payroll history for the same period from Payroll System

  1. Mail fraud report to <<insert where report is mailed>>
    • Mail copy to participant’s Counselor
  2. Program Administrator will take corrective action and contact F/EA to request additional information or to direct F/EA to take additional action
Internal Controls: 

The internal controls used by F/EA to monitor this process establish responsibility, segregate duties, document procedures and ensure independent internal verification.

  1. All information related to report of alleged fraud is recorded in Customer Service System
  2. <<Staff Title>> reviews completed fraud report and supporting documents prior to submission to Program Administrator
  3. <<Staff Title>> signs completed fraud report and supporting documents prior to submission to Program Administrator
  4. Fraud report and supporting documents are submitted to participant’s Counselor at the same time that they are submitted to Program Administrator
  5. Fraud report and supporting documents are maintained at F/EA