Fraud referrals – new claims & suspension

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  • #21468
    Accura
    Participant

    Hi

    at present if an assessor suspects fraud upon receipt of a new claim they will refer to the Fraud team. If subsequent investigation takes 3 months, and the claim can be paid this inevitably makes a dent in the time take to process.

    It is my understanding that an assessor can’t make a decision as to whether it is fraudulent, I am therefore suggesting that the claim is assessed and then suspended. This prevents a fraudulent payment and prevents incorrect recording of how long it took to make a decision – as long as we notify the customer (with appropriate wording)

    What do other sites do and is the above acceptable? 😕

    #5329
    Anselmo
    Participant

    I think your current process is probably what would have happened at my previous authority- but I would say it’s not right.

    You are under a duty to assess claims, and reg 91 gives you a real problem here- if you have sufficient info to process the claim, even if you have suspicions then reg 91 requires you to make at least interim payments after 14 days, so you’ll be risking overpayment anyway and might as well assess in full.

    You could indeed go down the route of assessing then suspending straight away on the grounds of avoiding potential overpayment but that does look, quite frankly, like it’s simply a way of massaging the figures. I suspect auditors may think so anyway.

    I just think if someone has established their entitlement you need to pay, and if you think they haven’t then you should either a) have a reasonable need for some further information, or b) refuse benefit and have the grounds to justify it on the facts you already hold. Innocent until proven guilty and all that. I do sympathise re overpayments and targets though.

    [DISCLAIMER: I don’t currently work at a local authority, and I’m not an expert in Fraud so don’t know of any possible rules or regs they may have that would help you achieve the outcome you’re after]

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