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5.9.1 Common instances of fraud
220.127.116.11 — The most common situations that require investigation and which may lead to prosecution are:
- deliberate, false or misleading statements on claim or review forms
- deliberate, false or misleading statements in relation to a claim for treatment
- deliberate failure to advise of a change in circumstances
- dual pension payments; and
- information from the public, i.e. denunciations.
18.104.22.168 — False statements are generally self-evident when comparing written documents to the actual facts of a case. Determining whether a failure to advise of a change in circumstances is deliberate may be more difficult. Such a decision should be made by looking at context, the history of previous advices from the client, the likelihood of them knowing a change had occurred and that it should be reported to DVA, etc.
The Commission approved Selection Criteria for Referral of Overpayment Cases for Investigation Leading to Possible Prosecution Action should be consulted to guide decision making. A summary of the selection criteria titled Summary of reasons to consider when submitting a case for possible prosecution can be found at:
Experience and judgement should be used, but when in doubt, refer the matter to the Business Compliance Section for further investigation.