Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/22/2024
8420
8430 Fraud Referral - Before a referral to the Office of the Medicaid Inspector General for prosecution of suspected fraud can be made, it is necessary for the agency to first determine the amount (if any) of the alleged fraudulent overstated eligibility by following the procedures outlined in 8340. The same act of alleged fraud repeated over a period of time shall not be separated so that separate penalties can be imposed. If it is decided that a case will not be prosecuted for fraud, then the overpayment shall be handled as a client overpayment as outlined in 8313. The burden of proving fraud is on the agency. All referrals shall be reviewed by the Eligibility Supervisor and Program Integrity Specialist prior to the referral being sent to the Office of the Medicaid Inspector General.
There is no minimum amount of alleged fraudulent overstated eligibility required to initiate a fraud referral.
Claims (individual program or combined) of less than $1001 are to be referred to an Administrative Disqualification Hearing.
Claims (individual program or combined) of $1001 and over are to be referred to the fraud unit who will determine the appropriate course of action.