13.4.1  Fraud Investigations

13.4.1.1 Referrals for Fraud Investigation

13.4.1.2 Timeliness of Fraud Investigation

13.4.1.3 Fraud Investigation Outcomes

A fraud investigation occurs to determine whether an individual intentionally misrepresented their eligibility criteria or committed an IPVIntentional Program Violation (see 13.5.1).

A fraud investigation referral can be for applicants and/or recipients of:

·        W-2Wisconsin Works payments and services; or

·        JALJob Access Loan.

In potential fraud cases:

·        An agency has reason to believe an overpayment is the result of intentional misrepresentation of program eligibility requirements as the result of:

·        False or misleading statements of circumstances, including income, assets, and household composition;

·        Failure to report a change in circumstances that would have led to decreased or discontinued payments;

·        Concealed or withheld facts; or

·        Violation of a program regulation or state statute relating to program eligibility.

·        A payment would not have been provided if case information had not been misrepresented.

13.4.1.1 Referrals for Fraud Investigation

The W-2 agency must initiate and process a fraud investigation referral by completing the following:

1. Determine whether the case meets the agency’s fraud referral criteria established in the agency’s standard operating procedures;

2. Review the allegations contained in the investigation referral;

3. Conduct the investigation in accordance with the agency’s standard operating procedures to substantiate the allegations of fraud;

4. Document the investigation in BRITSBenefit Recovery and Investigation Tracking System (see 13.1.5); and

5. Initiate an IPV, calculate and collect overpayments, and refer the case for prosecution, as necessary.

13.4.1.2 Timeliness of Fraud Investigation

The W-2 agency must conduct fraud investigations within 90 calendar days from the date the referral was created in BRITS.

If a fraud investigation is expected to exceed 90 days, the W-2 agency’s fraud representative must:

1. Record an extension due date in BRITS; and

2. Provide an explanation in BRITS comments.

When a W-2 agency designates fraud investigation activities to a third party, the W-2 agency is responsible for establishing procedures for requesting investigation extensions, including the criteria for approval or denial.

13.4.1.3 Fraud Investigation Outcomes

When the investigation finds that an individual intentionally misrepresented their information in order to become or remain eligible for W-2, or committed any other act that constitutes an intentional program violation (IPV), the W-2 agency may need to take one or more of the following actions:

1. Establish an IPVIntentional Program Violation (see 13.5.1);

2. Initiate a case closure to ensure no more improper payments are issued;

3. Determine whether the case meets the agency’s criteria for referral to the District Attorney for prosecution for fraud (see 13.5.1.2.3); and/or

4. Establish overpayment claims to attempt to recover any payments incorrectly paid to the individual as the result of the fraud (see 13.6).

If the investigation concludes that no fraud was committed, the W-2 agency must:

1. Ensure that the individual’s case remains open or reopens and there was no break in payments during the investigation; and

2. Process an auxiliary payment if the participant under investigation is owed any W-2 payments.

All fraud investigations must be completed and documented in BRITSBenefit Recovery and Investigation Tracking System, regardless of the outcome. For more information on BRITS, see 13.1.5.

History: Release 25-01; Release 20-01.