Part X, Subpart iv, Chapter 3, Section AFraud and Laboratory Analysis of Evidence

Occurs when an individual knowingly makes or causes to be made, conspires, combines, aids, or assists in, agrees to, arranges for, or in any way procures the making or presentation of a false or fraudulent certificate, statement, voucher, or paper concerning any claim.

Occurs when an individual who is entitled to or receiving benefits fails to provide information and all of the bullets below are true.

• The individual has knowledge of the facts on which eligibility for or entitlement to the benefits is based.
• The individual had knowledge of a change in circumstances and knew that such change could affect entitlement or eligibility.
• The individual chose not to notify VA of the change in circumstances with the actual intention of
  • receiving or obtaining benefit payments, or
  • retaining increased benefit payments.
• The individual received or retained benefit payments or increased benefit payments as a result of the intentional failure to disclose the change in circumstances.

Prepare a notice of proposed adverse action that notifies the beneficiary or fiduciary of

• the proposed adjustment, including the
  • revised rates, and
  • dates of payment
  • the reason for the adjustment
  • his/her right to present evidence to rebut the evidence serving as the basis for the proposed adjustment
  • the 60-day period, which begins on the date of the notice, for submitting evidence to show why the adjustment should not be made
  • his/her right to representation and a personal hearing, and
  • the fact that if VA receives a request for a hearing within 30 days of the date of the notice, VA will continue paying benefits at the present rate until the hearing is held and the testimony is reviewed.

Important: Avoid any mention of fraud in the notice of proposed adverse action. Note: Provide a copy of the notice of proposed adverse action to the OIG regional field office with jurisdiction over the RO that prepared the notice. References: For more information on

• preparing a notice of proposed adverse action, see M21-1, Part X, Subpart ii, 3.A, and
• the jurisdiction of OIG regional field offices, see M21-1, Part X, Subpart iv, 3.A.3.

Establish a suspense date that is 65 days from the date of the notice of proposed adverse action.

Did VA receive evidence within the 65-day period that would change the decision to adjust the beneficiary’s award?

• If yes ,
  • make any necessary adjustments to restore the award to its original state, and
  • take no further action.
• If no , go to the next step.

Amend the award for the appropriate periods effective the beginning date of the award or the day preceding the date of the fraudulent act, whichever is later, per 38 CFR 3.500(k). Note: Use the reason Fraud for each award adjustment resulting from fraud. Reference: For more information on adjusting an award for a fraudulent act, see the Veterans Benefits Management System Awards User Guide.

Is referral of the case to OIG appropriate, according to the instructions in M21-1, Part X, Subpart iv, 3.A.2.a?

• If yes , go to Step 8.
• If no , go to the next step.

Send to the beneficiary or fiduciary a decision notice that meets the requirements set forth in M21-1, Part VI, Subpart i, 1.B.

Does the fraud case involve foreign residency or domicile as discussed in M21-1, Part X, Subpart iv, 3.B.1.c?

• If yes ,
  • disregard the remaining steps in this table, and
  • follow the instructions in M21-1, Part X, Subpart iv, 3.B.
• If no , take no further action.

Does the fraud case involve foreign residency or domicile as discussed in M21-1, Part X, Subpart iv, 3.B.1.b?

• If yes , complete the remaining steps in this table while concurrently following the instructions in M21-1, Part X, Subpart iv, 3.B.
• If no , go to the next step.

After authorizing the award adjustment referenced in Step 4, send to the finance activity an encrypted e-mail that

• requests postponement of any collection action
  • cites M21-1, Part X, Subpart iv, 3, as the basis for the request, and
  • provides the following information:
    • file number
    • payee number
    • beneficiary’s name, and
    • date of the award adjustment.

Note: The beneficiary or fiduciary retains all rights, including the right to request a waiver of any overpayment which may result from the adjustment.

• Select and append the OIG Case corporate flash in Share.
  • Add the following system note: _ Fraud referral to OIG. Coordinate with OIG if waiver request is received_.

Reference: For more information on selecting and appending corporate flashes in Share, see the Share User Guide.

Send to the beneficiary or fiduciary a decision notice that meets the requirements set forth in M21-1, Part VI, Subpart i, 1.B. Important: In the decision notice, do not

• reference the right to request a waiver, or
• discuss collection of any debt arising from the adjustment.

Refer the case to OIG, citing beneficiary or fiduciary fraud under 38 CFR 3.901 or 38 U.S.C. 6102. Important:

• Refer cases to OIG only after completing development and making any necessary award adjustments.
  • Pension management centers (PMCs) must
    • e-mail a copy of their OIG referral to the Fraud Incident Team at VAVBAWAS/CO/FRAUDINCEDENTTEAM, and
    • include the words OIG Referral in the e-mail subject line.

Reference: For more information on referring cases of fraud to OIG, see M21-1, Part X, Subpart iv, 3.A.2.c.

• Establish end product (EP) 330 with a suspense date that is the first workday following a 60-day period that begins on the date of authorization of the award adjustment.
• Add Request for Special Report as a tracked item.
• After the suspense date passes, check the status of the OIG referral.

Did OIG respond within the 60-day suspense period?

• If yes ,
  • upload the response to the beneficiary’s electronic claims folder, and
  • go to the next step.
• If no ,
  • assume OIG will not pursue the case
  • instruct the finance activity to start collection action
  • clear the pending EP 330, and
  • disregard the remaining steps in this table.

Did OIG indicate it will pursue the case?

• If yes , go to the next step.
• If no ,
  • instruct the finance activity to start collection action
  • clear the pending EP 330, and
  • disregard the remaining step in this table.

• Refer the claims folder to OIG.
• Update the suspense date to one that is
  • consistent with OIG’s tentative date for resolution of the case, but
  • not more than six months in the future.

authorization activity

Uses Optional Form 41 , Routing and Transmittal Slip , plain bond paper, or a locally-developed fraud referral worksheet or memorandum to summarize the facts of the case, including

• the identities of individuals involved, as well as possible witnesses
  • a description of the alleged violation or fraudulent activity, including the date, time, and location, if known, and
  • an estimate of the corresponding overpayment.

Notes:

• Referrals should include, if available, the Social Security numbers of individuals involved and possible witnesses.
• In the absence of a local agreement to the contrary, do not routinely refer the claims folder to OIG at the time of the initial fraud referral.
• In unusual situations requiring immediate action, oral referrals may be made; however, these must later be confirmed in writing.
• In any case involving multiple allegations, make a separate referral for each allegation, with each allegation cross-referenced to the other. (Example: Employee aids a claimant in submitting a fraudulent claim.)

Veterans Service Center Manager, PMC Manager, or designee

Contacts the OIG regional field office with jurisdiction over the RO that is handling the case to make arrangements for OIG to review the case to determine whether investigation and prosecution is warranted. Reference: For more information on determining which OIG regional field office to contact, see M21-1, Part X, Subpart iv, 3.A.3.a.

OIG agent

Indicates which documents need to be copied for use by OIG and the U.S. Attorney.

Inspector General

Notifies the RO Director within 60 calendar days as to whether the case will be prosecuted.

General Counsel (02)

• Connecticut
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Office of Inspector GeneralCriminal Investigations DivisionNortheast Field Office275 Chestnut Street, Room 122Manchester, NH 03101-2485 Telephone : (603) 222-5866

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Office of Inspector General

Criminal Investigations Division
Mid-Atlantic Field Office
P.O. Box 27387
Washington, DC 20038 Telephone : (202) 530-9193

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Office of Inspector GeneralCriminal Investigations DivisionSoutheast Field Office7721 North Military Trail, Suite 5West Palm Beach, FL 33410-6410 Telephone : (561) 422-7720

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Office of Inspector General

Criminal Investigations Division
Central Field Office
P.O. Box 1454
Hines, IL 60140 Telephone : (708) 202-2676

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Office of Inspector GeneralCriminal Investigations DivisionSouth Central Field Office6900 Almeda Road, Room 1073Houston, TX 77030 Telephone : (713) 383-2793

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Office of Inspector GeneralCriminal Investigations DivisionWestern Field Office5120 Shoreham Place, Suite 200San Diego, CA 92122 Telephone : (858) 404-8332

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Office of Inspector General