H-8200, Procedures Relating to Overpayments

 

H-8210 Willful Withholding of Information

Revision 10-1; Effective March 1, 2010

In the Medicaid program, fraud means deliberate misrepresentation or willful withholding of information for the purpose of obtaining public assistance, either for self or another individual.

Clearly indicate willful withholding of information that affects eligibility or the amount of co-payment. Do not accuse recipients of fraud.

Reference: For further explanations of fraud referral procedures, refer to the Fair and Fraud Hearings Handbook.

Willful withholding of information includes:

  • willful misstatements, oral or written, made by a recipient or authorized representative in response to oral or written questions from the department concerning the recipient's income, resources or other circumstances that may affect the amounts of benefits. These misstatements may include understatements or omission of information about income and resources.
  • willful failure by the recipient or authorized representative to report changes in income, resources or other circumstances that may affect the amounts of benefits, if the department has clearly notified the recipient or authorized representative of his obligation to report these changes.

When a recipient or authorized representative signs the application/review form, he certifies that he understands that failure to fulfill his obligation to provide correct, complete information and to keep the department informed of changes may be considered willful withholding of information. Because of this willful withholding of information, the department is allowed to recover the overpayments.

 

 

H-8220 Overpayments Resulting from Suspected Fraud

Revision 10-1; Effective March 1, 2010

In cases of suspected fraud, follow these steps:

StepProcedure
1Certify continued assistance in the correct amount or deny the case. Observe notification of adverse action and appeal procedures.
2To report waste, abuse or fraud, please use the HHSC online reporting form at oig.hhsc.texas.gov, TIERS, GWS or call toll-free 1-800-436-6184.
3Complete periodic and special reviews while the case is investigated for suspected fraud. Contact the Investigations Division to determine whether the periodic review may cause problems or advise them of changes in circumstances. Example: The authorized representative who is suspected of willfully withholding information dies after the report is submitted to the Investigations Division. Contact the Investigations Division and advise them of the individual's death.

 

 

H-8230 Cases Not Submitted for Prosecution

Revision 10-1; Effective March 1, 2010

If the prosecuting attorney or the investigator determines that the case is not suitable for prosecution, the investigator tries to arrange a voluntary plan of restitution.

If the investigator does not arrange repayment, the MEPD staff is informed that the case not presented for prosecution and no plan of repayment arranged. Seek restitution for the amount of overpayment.

If the investigative unit does schedule repayment, you will be notified via Form H1018, Overpayment Claim. Seek restitution for the amount of the uncollected overpayment.