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. [x] 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. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Utilizing shared data from the Office of Family Independence (OFI) and Division of Support Enforcement and Recovery (DSER), the Lead Agency has identified application discrepancies between public assistance programs. Parents withdraw the application when they are unable to correct eligibility information. Programs that OCFS shares data with, such as TANF, will proceed with Fraud/Program violation if necessary. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. We pull data from our state audit process to help us identify overarching program needs while we continue to find efficient ways to monitor program-wide data. For FFY 24, a state audit identified 0 intentional program violations. We do not, at this time, track how many program violations were prevented by the above described activities of cross-checking program application information with other public assistance applications. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CCAP recovers monies in the amount $10.00 and over. Staff training on use and recovery process of share match is updated within the CCAP standard operating procedures. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. Of the state auditing data captured in FFY 2024, 9 unintentional program violations were identified and addressed. Of those 9, most had to do with missing or incorrect documentation. Our program specialists address and correct this as soon as the information is discovered. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: Utilizing shared data from OFI and DSER, the Lead Agency has been able to identify discrepancies between family data in the two programs and correct agency errors. CCAP recovers monies over the amount of $10.00 per agency error. Staff training is utilized when agency errors occur. Staff receive updates and training through information in emails, at staff meetings, and/or in updated standard operating procedures. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. State auditing data showed 50 agency errors were identified in FFY 24. We will continue to track this information. In each of these cases, we identified the origin of the error, corrected it directly, determined any relevant improper payment associated with it, and trained staff on how to prevent any future errors. State Auditing agency errors in FFY 2024 broke down into these topic areas: 9 missed documentation related to application and redetermination, 2 missed documentation of residency, 6 related to improper documentation of qualifying care, 15 related to improper documentation of financial requirements, and 18 related in improper calculation of award amounts/parent co-pays. These results have helped the management team shape both individual supervision and professional development work as well as group topics for common issues and errors across the team. b. [x] Run system reports that flag errors (include types). 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. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Lead Agency runs a report to flag any cases that do not have a parent fee assigned with a $0 value or higher. Lead Agency Runs a report if a parent fee exceeds Child Care Provider Rate. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. In FFY 24, all errors were tracked with their appropriate element number and notes on the cause of the error. From data pulled in state auditing processes, there were 50 agency errors total and broke down into these topic areas: 9 missed documentation related to application and redetermination, 2 missed documentation of residency, 6 related to improper documentation of qualifying care, 15 related to improper documentation of financial requirements, and 18 related in improper calculation of award amounts/parent co-pays. These results have helped the management team shape both individual supervision and professional development work as well as group topics for common issues and errors across the team. 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: The Lead Agency requires CCAP providers to provide attendance records for audit upon request. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. In FFY 24, state auditing data showed no intentional program violations were identified. We do take preventative measures to address program violations. including utilizing shared data from OFI/DSER. If the Lead Agency has identified application discrepancies between CCAP applications with applications for other public assistance programs, we would research the situation, identify errors or discrepancies and work to correct them. Parents withdraw the application when they are unable to correct eligibility information. Programs that OCFS shares data with, such as TANF, will proceed with Fraud/Program violation if necessary. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency requires CCAP providers to provide attendance records for audit upon request. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. In FFY 2024, state auditing data showed 9 unintentional program violations were identified and addressed. Of those 9, most had to do with missing or incorrect documentation. Our program specialists address and correct this as soon as the information is discovered. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency requires CCAP providers to provide attendance records for audit upon request. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. In FFY 24, state auditing data highlighted 9 administrative errors related to enrollment documents, attendance or billing records. Those were tracked with notes on the origin of the issue and reviewed to address the specific issues with both individual eligibility specialists as well as inform management plans for team- wide professional development and education. 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: The Lead Agency’s Quality Assurance Team audits a monthly random sample of cases. From the finding the Lead Agency conducts trainings and update the SOP. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. As discussed above, for FFY 24, 0 intentional program violations were identified in our state auditing process. Our supervisory staff have and continue to identify opportunities for individual and group training on how to prevent intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency’s Quality Assurance Team audits a monthly random sample of cases. From the finding the Lead Agency conducts trainings and update the SOP. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. For FFY 24 state auditing data, 9 unintentional program violations were identified. Our supervisory staff have and continue to identify opportunities for individual and group training on how to prevent unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency’s Quality Assurance Team audits a monthly random sample of cases. From the finding the Lead Agency conducts trainings and update the SOP. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. State Auditing data in FFY 24, 50 agency errors were identified and supervisory staff have addressed each with individual eligibility specialists as well as utilized this information to create preventative staff training. e. [x] Audit provider records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency audits random provider records to look at intentional program violations and accuracy in the eligibility and award process. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. State auditing data For FFY 24, 0 intentional program violations were found. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency audits random provider records to look at unintentional program violations and accuracy in the eligibility and award process. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. In state auditing data for FFY 24, 9 unintentional program violations were found. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency audits random provider records to look at agency accuracy. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. In state auditing data for FFY 24, 50 agency errors were identified. 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: The Lead Agency has a SOP for all child care affordability program staff and quality assurance team members. Training is also completed with information shared by email and at staff meetings. Training around intentional program violations helps staff members identify this violation correctly and consistently, understanding the most common types of intentional program violations. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. With information and data from state auditing in FFY 24, we are focused on training for continued prevention of intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency has a SOP for all child care affordability program staff and quality assurance team members. Training is also completed with information shared by email and at staff meetings. Training around unintentional program violations helps staff members identify this violation correctly and consistently, understanding the most common type of unintentional program violations. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. With the information from state auditing in FFY 24, staff supervisors are working to update SoPs and training opportunities to support prevention of future unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency has a SOP for all child care affordability program staff and quality assurance team members. Training is also completed with information shared by email and at staff meetings. Training is during onboarding and regularly with program staff to share knowledge of the most common agency errors and to improve coordination and program implementation and integrity to reduce those errors. CCAP is in the process of coding all the over/underpayments, intentional, and nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. With the information from state audit findings in FFY 24, all 50 agency errors have been noted, addressed directly with individual eligibility specialists and topics have been integrated into ongoing staff training opportunities. 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): DHHS Fraud Investigation Unit is responsible for recovery of Fraud and CCAP is responsible for recovery of overpayments. 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: The Lead Agency recovers payments over the amount of $10. In the new 2024 Rules, the Child Care Affordability Program (CCAP) clarified language to show that CCAP collects on administrative errors as well as provider and parent errors. CCAP now has one staff member to solely focus on Program Integrity and Recovery. A CCAP Specialist reviews a report for any errors in payments, age changes, et cetera. If the specialist suspects fraud, the case is passed on to the specialist handling program integrity who will take a deep dive into the case. The Program and Integrity specialist sets up and collects on all payment plans. By looking for administrative errors over $10, this activity assists the program in developing individual or group trainings and in resolving issues. Training may consist of 1 on 1 in supervisions, staff trainings, or emails. When nonintentional program violation occurs by provider error, CCAP has a Specialist available to meet with child care programs regarding billing questions/issues. The meetings can be in person or online. CCAP is in the process of coding all the over/underpayments, intentional, nonintentional program violations to align with the element numbers and reasons we will be using in our ACF 404 report. This report will help CCAP track any errors caught and fixed prior to any audit issues to help with identification of training needs. 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: The Lead Agency coordinates with the Fraud Investigation Unit. Fraud looks to see if the provider or parent utilize other benefits services such as MaineCare or SNAP. The D.A. in the geographical location decides to peruse cases brought forth to them by the fraud investigation unit. In 2023, the Child Care Affordability Program (CCAP) sent 23 cases to fraud. None of the cases sent in 2023 have been prosecuted through the Fraud Investigation Unit to this date. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will initiate recruitment of payments and then if need refer to DHHS Fraud Investigation Unit. The Child Care Affordability Program (CCAP) created a standard operating procedure (SOP) for the Program Integrity and Recovery Process as an appendix to the SOP guide for all CCAP Specialist and an email address for Program Integrity issues. CCAP sends out receipts after each payment is made with a prepaid envelope for the next payment to be sent in. By including the prepaid envelope, CCAP found payments to be more consistent. If CCAP does not receive a payment, a 2nd notice will be sent. If the repayment plan is for a child care provider, CCAP will note, "online billing hold, program please contact CCAP." If the parent or provider defaults from the payment arrangements, they will be removed from the program. The SOP updates, letters, and faster communication with clients has streamlined the payment plan process. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: The lead agency will reduce payments through vendor ledger adjustments. The Child Care Affordability Program (CCAP) found vendor ledger adjustments in our current MACWIS system (child care management system) were harder to track and payments by check and money order have been preferred. If a child ended care, changed child care providers, or had a redetermination, the CCAP staff must remember to add back in the vendor adjustments. This resulted in a new vendor adjustment system built into Baxter, the new child care management system being implemented in 2025. The new vendor adjustments are tied to the specific provider file and not the child’s file. v. [x] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: The Leads Agency will refer case to the DHHS Fraud Investigation Unit pursuant to Title 22 M.R.S 13. vi. [x] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will accept payment by check and money order. 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: When the Department makes a preliminary determination that a parent or child care provider may have committed a program violation, the case may be referred to the DHHS Fraud Investigation Unit pursuant to Title 22 M.R.S. §13 and the Department may pursue establishment of a program violation against the parent and/or child care provider administratively. The Unit is comprised of the Deputy Director Fraud Investigation and Recovery Unit and Fraud Investigators under said department. A final determination that a program violation was made shall be made only as the result of a decision made by an Administrative Hearing, a court, or waiver of the Administrative Hearing by the parent and/or child care provider. Failure to request an Administrative Hearing constitutes a waiver. Child care providers who previously had agreements with the Department and who were found to be engaged in fraud or a program violation in connection with the Child Care Subsidy program or have been sanctioned are not eligible to receive payments on behalf of parents receiving Subsidy. Improper payments are managed within CCAP and letters are sent requesting payment. Checks are processed within the CCAP unit or vendor adjustments are made in accordance with payment plans. viii. [ ] Other. Describe the activities and the results of these activities: 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: The Lead Agency recovers a minimum dollar amount of an improper payment and identify the minimum dollar amount as over $10. ii. [ ] 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: iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will initiate recoupment of payments and then if needed, refer the case to the DHHS Fraud Investigation Unit. The Lead Agency has recouped $615.15 for Provider nonintentional improper payments. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will initiate recoupment of payments and then if needed, refer the case to the DHHS Fraud Investigation Unit. The lead agency has the option to create vendor with holdings for future months. v. [x] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will refer cases to the DHHS Fraud Investigation Unit pursuant to Title 22 M.R.S. §13. The Lead Agency does not have access as of yet to the results of providers with sanctions of tax intercepts. vi. [x] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will accept payments by check. vii. [ ] 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: 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: The Lead Agency recovers a minimum dollar amount of an improper payment and identify the minimum dollar amount as over $10. 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: The Lead Agency refers cases to the DHHS Fraud Investigation Unit if necessary. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will initiate recoupment of payments. In FY 23 the Lead Agency recovered $1,509.32. In Agency error. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency will initiate recoupment of payments. The Lead Agency has the option of creating a vendor with holding for future payments. will initiate recoupment of payments and then if needed, refer the case to the DHHS Fraud Investigation Unit. 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. [ ] 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: 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: The Client has ten (10) days to appeal the decision. If there was an intentional program violation by the Client, the Lead Agency shall impose a disqualification penalty for up to twelve (12) months. For the last quarter of SFY24, the Lead Agency had 1 identified CCAP parent requiring reimbursement to the provider prior to being able to submit a new application. The parents sent the recoupment of payment to the provider and submitted a new CCAP application. 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: The Provider has ten (10) days to appeal the decision. If there was an intentional program violation by the Provider, the Lead Agency shall impose a disqualification penalty for up to twelve (12) months. iii. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: DHHS Fraud Investigation Unit works with law enforcement when a case has been referred to fraud. For FFY 23, there were no criminal charges. 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: