10.2 Fraud Investigation, Payment Recovery, and Sanctions

Lead Agencies must have the necessary controls to identify fraud and other program violations to ensure program integrity. Program violations can include both intentional and unintentional client and/or provider violations, as defined by the Lead Agency. These violations and errors, identified through the error-rate review process and other review processes, may result in payment or nonpayment (administrative) errors and may or may not be the result of fraud, based on the Lead Agency definition. 10.2.1 Strategies used to identify and prevent program violations Check the activities the Lead Agency employs to ensure program integrity, and for each checked activity, identify what type of program violations the activity addresses, describe the activity and the results of these activities based on the most recent analysis. a. [ ] Share/match data from other programs (e.g., TANF program, Child and Adult Care Food Program, Food and Nutrition Service (FNS), Medicaid) or other databases (e.g., State Directory of New Hires, Social Security Administration, Public Assistance Reporting Information System (PARIS)). i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: b. [x] Run system reports that flag errors (include types). i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ELCs/RCMA run a SR Duplicate Payment Report to detect and help prevent potential duplicate payments between multiple providers and coalitions regarding CCDF subsidies. Cases identified with errors require payment adjustment. When payments or attendance are duplicated then case corrections and adjustments are made. DEL also provides technical assistance as needed. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: In addition to the SR Duplicate Payment Report mentioned above, DEL also runs a Total Family Income Exceeds 85 percent SMI Report to detect and help prevent payments in error to families with total household gross annual income exceeding 85 percent of the SMI (does not apply to at risk protective services). Cases identified with errors require payment adjustment(s). Families identified as over-income are provided a 14-day notice. DEL also provides technical assistance as needed. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: ELCs run the SR Duplicate Payments and Total Family Income Exceeds 85 percent SMI Reports monthly. The ELCs can complete an analysis and detect errors to identify areas for correction. c. [x] Review enrollment documents and attendance or billing records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ELCs/RCMA are required to conduct post attendance monitoring of provider reimbursement submissions. DEL conducts biennial monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. Monitoring helps identify and help prevent eligibility, attendance, and payment errors. Cases identified with errors require payment adjustment(s). Corrective actions include providing instructions for payment adjustments, requiring supporting documentation to be available for inspection upon request, performing follow-up tasks, and offering technical assistance as needed. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ELCs/RCMA are required to conduct post attendance monitoring of provider reimbursement submissions. DEL conducts biennial monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors. Cases identified with errors requiring payment adjustment(s) are provided instructions for the payment adjustments, follow up tasks to perform and offered technical assistance as needed. Supporting documentation is required to be available for inspection upon request. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: ELCs/RCMA are required to conduct post attendance monitoring of provider reimbursement submissions. DEL conducts biennial monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors. Cases identified with errors requiring payment adjustment(s) are provided instructions for the payment adjustments, follow up tasks to perform and offered technical assistance as needed. Supporting documentation is required to be available for inspection upon request. d. [x] Conduct supervisory staff reviews or quality assurance reviews. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Rule 6M-4.208(1), F.A.C., requires the ELC/RCMA or its designee to conduct internal file monitoring activities to ensure the accuracy of eligibility determinations. DEL conducts biennial monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors. Cases identified with errors requiring payment adjustment(s) are provided instructions for the payment adjustments, follow up tasks to perform and offered technical assistance as needed. Supporting documentation is required to be available for inspection upon request. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Rule 6M-4.208(1), F.A.C., requires the ELC/RCMA or its designee to conduct internal file monitoring activities to ensure the accuracy of eligibility determinations. DEL conducts biennial monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors. Cases identified with errors requiring payment adjustment(s) are provided instructions for the payment adjustments, follow up tasks to perform and offered technical assistance as needed. Supporting documentation is required to be available for inspection upon request iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Rule 6M-4.208(1), F.A.C., requires the ELC/RCMA or its designee to conduct internal file monitoring activities to ensure the accuracy of eligibility determinations. DEL conducts biennial monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors to resolve cases identified with errors requiring payment adjustment(s). Corrective actions include providing instructions for payment adjustments, require supporting documentation to be available for inspection upon request, perform follow-up tasks, and offer technical assistance as needed. e. [x] Audit provider records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ELCs/RCMA are required to conduct post attendance monitoring of provider reimbursement submissions. In addition, ELCs/RMCA conduct on-site contract compliance monitoring of a sample of childcare providers annually. DEL conducts biennial program monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors to resolve instances of compliance violations and/or improper payments identified. Corrective actions include providing instructions for payment adjustments, requiring supporting documentation to be available for review upon request, following up on corrective actions, and providing technical assistance as needed. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ELCs/RCMA are required to conduct post attendance monitoring of provider reimbursement submissions. In addition, ELCs/RCMA conduct on-site contract compliance monitoring of a sample of childcare providers annually. DEL conducts biennial program monitoring of ELCs and RCMA that includes a review of eligibility determinations, attendance, and payment validation. The purpose of this activity is to identify and help prevent eligibility, attendance, and payment errors to resolve instances of compliance violations and/or improper payments. Corrective actions include providing instructions for payment adjustments, requiring supporting documentation to be available for review upon request, following up on corrective actions, and providing technical assistance as needed. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: DEL runs a SR Duplicate Payments report to detect and help prevent potential duplicate payments between multiple providers and coalitions. The report results in cases identified with errors requiring payment adjustment(s). Corrective actions include case corrections and adjustments when payments or attendance are duplicated. DEL also provides technical assistance. DEL runs a Total Family Income Exceeds 85 percent SMI report to detect and help prevent payments in error to families with total household gross annual income exceeding 85 percent of the SMI (does not apply to at risk protective services). When cases are identified with errors, a 14-day notice to over income families is required to conduct payment adjustment(s). f. [x] Train staff on policy and/or audits. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: DEL monitoring and CCDF policy staff are continuously trained on CCDF policy and monitoring practices beginning on the first day of employment. Staff also participate (on a regular basis) in external trainings on contract management, monitoring practices, and uniform grant guidance. Additionally, several of the monitoring/policy team staff are Florida Certified Contract Managers (FCCM), which is a professional state-awarded designation that is renewed every four years. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: DEL monitoring and CCDF policy staff are continuously trained on CCDF policy and monitoring practices beginning on the first day of employment. Staff also participate (on a regular basis) in external trainings on contract management, monitoring practices, and uniform grant guidance. Additionally, several of the monitoring/policy team staff are FCCM, which is a professional state-awarded designation that is renewed every four years. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: DEL monitoring and CCDF policy staff are continuously trained on CCDF policy and monitoring practices beginning on the first day of employment. Staff also participate (on a regular basis) in external trainings on contract management, monitoring practices, and uniform grant guidance. Additionally, several of the monitoring/policy team staff are FCCM, which is a professional state-awarded designation that is renewed every four years. g. [ ] Other. Describe the activity(ies): i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: 10.2.2 Identification and recovery of misspent funds Lead Agencies must identify and recover misspent funds that are a result of fraud, and they have the option to recover any misspent funds that are a result of unintentional program violations or agency errors. a. Identify which agency is responsible for pursuing fraud and overpayments (e.g., State Office of the Inspector General, State Attorney): ELCs/RCMA refer suspected fraud cases through the FLDOE Office of Inspector General (FLDOE OIG) to the Florida Department of Financial Services (DFS), Division of Public Assistance Fraud (DPAF) for criminal investigation. If the criminal investigation results in court ordered restitution, those restitution payments are remitted to DEL for redistribution into the child care system or repayment to ACF depending on the period of availability of the grant funding. The FLDOE OIG does not collect improper payments. b. Check and describe all activities, including the results of such activity, that the Lead Agency uses to investigate and recover improper payments due to fraud. Consider in your response potential fraud committed by providers, clients, staff, vendors, and contractors. Include in the description how each activity assists in the investigation and recovery of improper payment due to fraud or intentional program violations. Activities can include, but are not limited to, the following: i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: There is $0.00 threshold for each instance of fraud or intentional program violations, especially if there is court-ordered restitution. During the 2022-2023 state fiscal year, DEL collected a total of $120,079.14 in restitution payments. ii. [x] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: ELCs/RCMA refer suspected fraud cases through the FLDOE OIG to DPAF for criminal investigation. During the 2022-2023 state fiscal year, activities related to recipient and/or provider fraud cases resulted in: 169 cases referred to DPAF for criminal investigation, 78 cases not investigated by DPAF, 86 cases in screening status or pending assignment to a DPAF investigator, and 4 cases awaiting a status as of the end of the fiscal year. DPAF was actively investigating one case at year end. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Recovery of Unintentional Program Violations (UPV) improper payments is typically done at the ELC/RCMA level. Improper payments made to childcare providers are recovered through offsetting subsequent reimbursements (adjusting) for the improper payment amount (if the provider is still under contract). A provider may request that adjustments be made through a repayment plan. Parent copay errors are corrected via adjustments to future copayments iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Recovery of improper payments that are caused by UPVs or administrative errors is typically done at the local ELC/RCMA level in accordance with DEL Program Guidance 240.01 and Rule 6M-400, F.A.C., which instructs the ELCs/RCMA how to manage funding when addressing audit and monitoring disallowances, refunds, and court-ordered restitution. Improper payments are then forwarded to DEL, if applicable. v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [x] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: FLDOE has an OIG, which consists of an Inspector General, a Director of Early Learning Fraud Prevention, and a Management Review Specialist. The mission of the FLDOE OIG is to protect and promote public integrity and accountability within DEL through audits and investigations that detect fraud, waste, abuse, and administrative violations. The OIG also administers the public assistance fraud referral process for DEL and coordinates the process with external partners to ensure maximum efficiency. Section 1002.91(8), F.S., also requires the local ELCs to adopt an anti-fraud plan, to be approved by the FLDOE OIG. Rule 6M-9.400, F.A.C., further delineates the responsibilities of ELCs/RCMA when implementing their anti-fraud plans. The anti- fraud plan must be approved by the ELC/RCMA board prior to submission to the FLDOE OIG no later than June 30 of each year. The FLDOE OIG will process the plan no later than September 1 of each year and shall notify the ELC/RCMA in writing of approval or disapproval and the reasons for disapproval. If disapproved, a corrected plan shall be submitted no later than November 1 of each year. Additionally, ELCs/RCMA have identified personnel with the responsibility of fraud prevention and detection in accordance with their approved anti-fraud plan. In addition, each ELC and RCMA are responsible for fraud prevention at the local level and have designated staff that assist with fraud prevention, detection, and investigation. viii. [x] Other. Describe the activities and the results of these activities: Section 1002.91(2), F.S., requires the department to investigate ELCs, recipients, and providers of SR program and the VPK Education Program to determine possible fraud or overpayment and recover state, federal, and local matching funds. For IPVs, ss. 1002.84(18), and 1002.91(8), F.S., requires the ELCs/RCMA to implement an anti-fraud plan to address the detection, reporting, and prevention of overpayment, abuse, and fraud relating to the provision of and payment for the SR and VPK Programs. The anti-fraud plan must be approved by the ELC/RCMA board and, ultimately, the FLDOE OIG. Rule 6M-9.400, F.A.C., further delineates the responsibilities of ELCs when implementing their anti-fraud plans. c. Does the Lead Agency investigate and recover improper payments due to unintentional program violations? [ ] No. [x] Yes. If yes, check and describe below any activities that the Lead Agency will use to investigate and recover improper payments due to unintentional program violations. Include in the description how each activity assists in the investigation and recovery of improper payments due to unintentional program violations. Include a description of the results of such activity. i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: DEL does not require recovery. However, DEL does require that ELCs/RCMA implement corrective actions, at the point of discovery, to mitigate any future improper payments. This also includes review of operations for a specified/to-be-determined period to determine if other similar improper payments may have occurred. ii. [x] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: By way of DEL’s fiscal and programmatic monitoring sections, observations of improper payments that are discovered during monitoring engagements are compiled and sent to ELCs and the RCMA via monitoring reports. Recovery of improper payments that are caused by UPVs or administrative errors is typically done at the local ELC/RCMA level in accordance with DEL Program Guidance 240.01 and Rule 6M-4.400, F.A.C., which instructs the ELCs/RCMA how to manage funding when addressing audit and monitoring disallowances, refunds, and court ordered restitution. Improper payments are then forwarded to DEL, if applicable. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Recovery of UPV improper payments is typically done at the ELC/RCMA level. Improper payments made to childcare providers are recovered through offsetting subsequent reimbursements (adjusting) for the improper payment amount (if the provider is still under contract). A provider may request that adjustments be made through a repayment plan. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Recovery of UPV improper payments is typically done at the ELC/RCMA level. Improper payments made to childcare providers are recovered through offsetting subsequent reimbursements (adjusting) for the improper payment amount (if the provider is still under contract). A provider may request that adjustments be made through reducing the amounts of subsequent reimbursements until the improper payment is reconciled. v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [x] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: By way of DEL's fiscal and programmatic monitoring sections, observations of improper payments that are discovered during monitoring engagements are compiled and sent to ELCs and the RCMA via monitoring reports. In addition, under the statewide information system, the programmatic monitoring section reviews system generated reports that identify potential errors that could result in UPVs. If improper payments are validated via the monitoring reports or the statewide information system generated reports, ELCs and the RCMA are required to recover all overpayments that are feasible. viii. [ ] Other. Describe the activities and the results of these activities: d. Does the Lead Agency investigate and recover improper payments due to agency errors? [ ] No. [x] Yes. If yes, check and describe all activities that the Lead Agency will use to investigate and recover improper payments due to agency errors. Include in the description how each activity assists in the investigation and recovery of improper payments due to administrative errors. Include a description of the results of such activity. i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: ELCs/RCMA shall not take action to recover an incorrect parent co-payment (from a provider or parent) made due to an error of the ELC/RCMA. However, DEL does require ELCs/RCMA to implement corrective actions, at the point of discovery, to mitigate any future improper payments. This also includes review of operations for a review period to determine if other similar improper payments may have occurred. ii. [x] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: Recovery of improper payments that are caused by UPVs or administrative errors is typically done at the local ELC/RCMA level in accordance with DEL Program Guidance 240.01 and Rule 6M-4.400, F.A.C., which instructs the ELCs/RCMA how to manage funding when addressing audit and monitoring disallowances, refunds, and court- Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: ordered restitution. Improper payments are then forwarded to DEL, if applicable. iii. [ ] iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Recovery of improper payments that are caused by UPVs or administrative errors is typically done at the local ELC/RCMA level in accordance with DEL Program Guidance 240.01 and Rule 6M-4.400, F.A.C., which instructs the ELCs/RCMA how to manage funding when addressing audit and monitoring disallowances, refunds, and court-ordered restitution. Improper payments are then forwarded to DEL, if applicable. v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ]Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [x] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: By way of DEL's fiscal and programmatic monitoring sections, observations of improper payments that are discovered during monitoring engagements are compiled and sent to ELCs and the RCMA via monitoring reports. In addition, under the statewide information system, the programmatic monitoring section reviews system generated reports that identify potential errors that could result in UPVs. If improper payments are validated via the monitoring reports or the statewide information system generated reports, ELCs and the RCMA are required to recover all overpayments that are feasible. viii. [ ] Other. Describe the activities and the results of these activities: e. What type of sanction will the Lead Agency place on clients and providers to help reduce improper payments due to intentional program violations or fraud? Check and describe all that apply: i. [x] Disqualify the client. Describe this process, including a description of the appeal process for clients who are disqualified. Describe the activities and the results of these activities based on the most recent analysis: Rule 6M-9.400, F.A.C., requires the ELC to provide written advance notice of the intended action to suspend or terminate benefits to the recipient to be affected and it must clearly advise of the allegations, the basis of the allegations, the intended action, and the date the action is to be imposed. The ELC shall send the written advance notice at least 14 calendar days before the intended action. The length of time for which the recipient's benefits are suspended or the date of the termination of benefits shall be proportionate to the alleged offense committed, consistent with suspensions or terminations issued to other recipients who allegedly committed comparable offenses, and may also consider prior offenses, as appropriate. A suspension or termination shall not be applied against recipients with a valid at- risk referral. If the recipient believes that the issue was not resolved by the ELC, the recipient may file a formal written appeal for review by the executive director of the ELC that must be postmarked or emailed before the date of the intended action, whichever is later. If the recipient files a timely appeal, he or she will not be suspended or terminated from the program until the written decision of the executive director or the original date of the intended action, whichever is later. The executive director of the ELC or other executive staff person designated by the ELC board must respond to the recipient, in writing, within 30 days of receiving the appeal with a decision as to whether the suspension or termination will be upheld or modified. The recipient who wishes to appeal the decision of the executive director of the ELC or other executive staff person designated by the ELC board may request further review by an appeals committee within 10 calendar days of the date of the executive director or other executive staff person designated by the ELC board's written response to the recipient's formal written appeal. The appeals committee shall be convened within 45 calendar days of receipt of the recipient's request for an appeal. The appellant shall be notified in writing of the appeals committee's determination within 10 days of the date of the meeting. The determination of the appeals committee shall be final. ii. [x]Disqualify the provider. Describe this process, including a description of the appeal process for providers who are disqualified. Describe the activities and the results of these activities based on the most recent analysis: In accordance with s. 1002.91(4), F.S., the ELC may suspend or terminate the provider from participating in the SR Program when it has reasonable cause to believe the provider has committed fraud. If suspended, the provider shall remain suspended until the completion of any investigation by DEL, DFS, or any other state or federal agency, and subsequent prosecution or other legal proceeding. The provider may request in writing a review of the determination made by the ELC within five business days of receipt of notice of the determination, which the provider believes to be incorrect. If the ELC receives a request for a review hearing from the provider, the ELC must address the request by assigning a review hearing committee within three days of the request and must send a written response to the provider within five days of the request. The hearing must convene within 45 days of the request. Within five business days of receipt of the response to a request for a review hearing, the provider must inform the ELC of the preferred date and time of the hearing and whether the provider will meet in person or via a method of telecommunication. Following completion of the presentation by the provider and the ELC, the review hearing committee will vote regarding each of the provider's claims. A written notice of the review-hearing conclusion is given to the provider that states the outcome of each of the provider's claims and reasons supporting the committee's decision. The decision of the Review Hearing Committee is final. iii. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: Parents and providers suspected of fraudulent activities are referred to the Office of Inspector General for staff to validate the referral within 72 hours of entry into the fraud referral system. If warranted, the referral is then submitted to DPAF for further investigation. If there is enough evidence to support legal action, then restitution and or criminal penalties could be imposed which may include removal from the SR program. iv. [ ] Other. Describe the activities and the results of these activities based on the most recent analysis: Appendix 1: Lead Agency Implementation Plan The Appendix will be available for Lead Agencies to use in CARS after the Plan approval letter is issued. For each non-compliance, Lead Agencies must describe the following: • Action Steps: List the action steps needed to correct the finding (e.g., update policy manual, legislative approval, IT system changes, etc.). For each action step list the: o Responsible Entity: Indicate the entity (e.g., agency, team, etc.) responsible for completing the action step. o Expected Completion Date: List the expected completion date for the action step. • Overall Target Date for Compliance: List date Lead Agency anticipates completing implementation, achieving full compliance with all aspects of the findings. (Note: Compliance will not be determined until the FFY 2025-2027 CCDF Plan is amended and approved). Appendix 1: Form [Plan question with non-compliance and associated provision will pre-populate based on preliminary notice of non-compliance] A. Action Steps for Implementation B. Responsible Entity(ies) C. Expected Completion Date Step 1: Step 2 (as necessary): [Additional steps added as necessary] Overall Target Date for Compliance: