11200 Determination of Fraud - A fraud error can only be established through a finding by a court of appropriate jurisdiction. Therefore additional steps are required before collection action may commence.
A suspected fraud error shall be referred to the KDHE-DHCF Legal Division. The Legal Division will make a determination as to whether or not to pursue the case in court. If a decision is made not to pursue, the claim will be labeled as Client Error and processed as such. If the claim is accepted by the Legal Division for prosecution, no further action shall be taken until a decision by the court has been rendered.
Individuals should not receive notice that the case is under investigation for fraud. Client inquiries concerning the possible fraud investigation should be responded with a statement that the case is “under administrative review.” No additional information should be provided.
11210 Definition of Fraud - A fraudulent error occurs when the client intentionally:
1. Makes false or misleading statement, misrepresentation, concealment, or withholding of facts for the purpose of improperly establishing or maintaining eligibility [see 11221 (3)]; or
2. Misuses medical benefits, including selling, sharing or trading the medical I.D. number for money or other renumeration, signing for services that were not provided to the recipient, or other misuse as determined by the agency.
An individual shall be considered to have committed fraud when the individual has been legally determined to have committed fraud through a court of appropriate jurisdiction. There is no other method of establishing a fraud claim.
A finding of fraud under these provisions
may result in criminal penalty, including fines and imprisonment, but
may only result in a period of ineligibility if so ordered by the court
(see 11126.2). Fraud error status is not established if the court’s
resolution to the willful client error is to place the individual on diversion.