910.3 How Are Overpayments Discovered

PO18576910 - Processing MA Overpayments for individuals enrolled in the HIPP Program - July 10, 2017

Evidence of possible overpayments comes from many sources which include, but are not limited to the following:

55 Pa. Code § 255.4(a)

• The individual. The individual reports a change in circumstances that may cause the individual to become ineligible for benefits. The CAO will complete a review of eligibility when the individual reports a change in circumstances to determine if the individual is overpaid;

NOTE: A cash overpayment may occur even if the individual reported the change in circumstances timely and accurately.

• The DHS’s Bureau of Program Evaluation, Division of Quality Control. Quality Control will review a random sample of active and closed cases. Quality Control will inform the CAO of any unreported resource or circumstance discovered during the review. The CAO will review the case and determine whether an overpayment occurred;

55 Pa. Code § 255.4(a)(2)

• The community. When letters and telephone calls are received from persons in the community who want to report alleged welfare fraud or abuse, the CAO will refer the complaints to the appropriate worker. The worker will review and determine if an overpayment occurred.

NOTE: For the SSP program, CAOs may obtain overpayment information from:

(1) Treasury; or
(2) from the Social Security Administration (SSA); or
(3) in OnBase at the Check Disbursement Inquiry screen, or from the SSP Central Unit.

NOTE: Overpayments identified by Treasury will be referred in writing to DHS, Bureau of Operations, and subsequently forwarded to the appropriate CAO Executive Director for action.

The CAO will ensure that the identity of the persons who report alleged welfare fraud or abuse are kept confidential when investigating these complaints. The names may not be revealed to the individuals under any circumstances. This procedure is necessary to protect the persons making complaints from potential harm including reprisal.

The CAO will not require persons making complaints to give their name. All complaints will be investigated regardless of identification;

• Automated information sources. Automated information sources compare DHS individual information with financial information provided by third parties. When a CAO receives confirmation of a match, it will review the information to determine if an overpayment occurred.

55 Pa. Code § 255.4(a)

Examples of automated information sources are:

• Income Eligibility Verification System (IEVS) match;

• lottery prize winners match;

• duplicate names and dates of birth match;

• bank account match;

• interstate recipient match;

• state employee match;

• federal employee match; and

• prison match.

• Adverse hearing decision. An overpayment may occur if an individual continues to receive benefits pending a hearing decision, and the hearing decision is adverse to the individual;

55 Pa. Code § 255.3(c)

• Auditor General. The Auditor General’s Office reviews a sample of records during periodic audits of CAOs. Overpayments may be discovered through an audit exception;

• OSIG’s Tip line. Telephone calls to the fraud tip line are screened for possible overpayments occurring as a result of fraud. Telephone calls that are not investigated by the OSIG are referred to the CAO to review and determine if an overpayment occurred;

• Review of case records. The CAO supervisory review of case records and other internal reviews; and

• Review of closed cases. The CAO will review any case closings due to income to verify the amount and date that the income began. If an overpayment has occurred, a referral to OSIG is required.

55 Pa. Code § 255.3(d)

When an individual voluntarily requests that his case be closed, the CAO will obtain information from the individual about the reasons for the closing. The CAO will determine if the closing was timely and whether an overpayment occurred.

If the individual does not provide the reason for requesting that his case be closed and the CAO is unable to obtain the information, the CAO will note in the case record that the case was closed without the individual’s input. At a subsequent application by the same individual, the CAO will:

• verify that the resource or reason that caused the case closure no longer exists;

• explore a possible overpayment; and

• review the credibility and reliability of the individual in reporting changes.

Reissued March 24, 2021, replacing August 13, 2013