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: The Lead Agency, the SNAP program, and the TANF program share data regarding recipients to assist in validating facts submitted by the recipient for review and to assist in identification and prevention of fraud and intentional program violations. Data sharing is also used to acquire information, including any missing information, during the application process to prevent ineligible applicants from approval for the program. or tap here to enter text. The result of this practice is that information is verified across programs which reduces the potential for intentional program violation or fraud. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Transactional child care activity is monitored and analyzed through the Lead Agency's Child Care Payment Program system (CCPP). Through CCPP, the Lead Agency runs error reports that flag inaccuracies including duplicate certificates, duplicate children at a provider, comments from providers that need to be addressed, children over the age of six (6) who are receiving full-time certificates, referral errors for TANF clients, and clients with active certificates who are coded as TANF or TCC, but who do not exist in the TANF database. This results in the Lead Agency being able to avoid issuing duplicate/erroneous payments, therefore reducing the need to recoup funding because an improper payment occurred. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: Transactional child care activity is monitored and analyzed through the Lead Agency's Child Care Payment Program system (CCPP). Through CCPP, the Lead Agency runs error reports that flag inaccuracies including duplicate certificates, duplicate children at a provider, comments from providers that need to be addressed, children over the age of six (6) who are receiving full- time certificates, referral errors for TANF clients, and clients with active certificates who are coded as TANF or TCC, but who do not exist in the TANF database. This results in the Lead Agency being able to avoid issuing duplicate/erroneous payments, therefore reducing the need to recoup funding because an improper payment occurred. 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: Transactional child care activity is monitored and analyzed through the Lead Agency's Child Care Payment Program system (CCPP). Through CCPP, the Lead Agency runs error reports that flag inaccuracies including duplicate certificates, duplicate children at a provider, comments from providers that need to be addressed, children over the age of six (6) who are receiving full-time certificates, referral errors for TANF clients, and clients with active certificates who are coded as TANF or TCC, but who do not exist in the TANF database. This results in the Lead Agency being able to avoid issuing duplicate/erroneous payments, therefore reducing the need to recoup funding because an improper payment occurred. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Transactional child care activity is monitored and analyzed through the Lead Agency's Child Care Payment Program system (CCPP). Through CCPP, the Lead Agency runs error reports that flag inaccuracies including duplicate certificates, duplicate children at a provider, comments from providers that need to be addressed, children over the age of six (6) who are receiving full-time certificates, referral errors for TANF clients, and clients with active certificates who are coded as TANF or TCC, but who do not exist in the TANF database. This results in the Lead Agency being able to avoid issuing duplicate/erroneous payments, therefore reducing the need to recoup funding because an improper payment occurred. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Transactional child care activity is monitored and analyzed through the Lead Agency's Child Care Payment Program system (CCPP). Through CCPP, the Lead Agency runs error reports that flag inaccuracies including duplicate certificates, duplicate children at a provider, comments from providers that need to be addressed, children over the age of six (6) who are receiving full- time certificates, referral errors for TANF clients, and clients with active certificates who are coded as TANF or TCC, but who do not exist in the TANF database. This results in the Lead Agency being able to avoid issuing duplicate/erroneous payments, therefore reducing the need to recoup funding because an improper payment occurred. 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 reviews ledgers for enrollment, attendance, or billing misrepresentations. The Lead Agency may refer any persons or providers believed to be in violation of our policy to the Division of Program Integrity for investigation. Investigations include, but are not limited to, reviewing enrollment and other documentation, reviewing sign in and sign out sheets, and conducting an on-site visitation. Further, the Lead Agency's Office of the Inspector General Division of Program Integrity department can pull random samples and refer for investigation if warranted. This practice results in the Lead Agency being able to assess staff knowledge and identify where additional training is needed. Training occurs with the Deputy Director on a monthly basis, or as needed whichever is more frequent. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency reviews ledgers for enrollment, attendance, or billing misrepresentations. The Lead Agency may refer any persons or providers believed to be in violation of our policy to the Division of Program Integrity for investigation. Investigations include, but are not limited to, reviewing enrollment and other documentation, reviewing sign in and sign out sheets, and conducting an on-site visitation. Further, the Lead Agency's Office of the Inspector General Division of Program Integrity department can pull random samples and refer for investigation if warranted. This practice results in the Lead Agency being able to assess staff knowledge and identify where additional training is needed. Training occurs with the Deputy Director on a monthly basis, or as needed whichever is more frequent. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency reviews ledgers for enrollment, attendance, or billing misrepresentations. The Lead Agency may refer any persons or providers believed to be in violation of our policy to the Division of Program Integrity for investigation. Investigations include, but are not limited to, reviewing enrollment and other documentation, reviewing sign in and sign out sheets, and conducting an on-site visitation. Further, the Lead Agency's Office of the Inspector General Division of Program Integrity department can pull random samples and refer for investigation if warranted. This practice results in the Lead Agency being able to assess staff knowledge and identify where additional training is needed. Training occurs with the Deputy Director on a monthly basis, or as needed whichever is more frequent. 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: Lead Agency supervisors perform a yearly Performance Review Assessment that includes reviews of the staff by the supervisor and self-evaluation reviews by all staff. In addition, all staff perform peer reviews periodically. Peer reviews include reviewing completed applications worked by co- workers. This practice deepens staff knowledge through the peer- review process and helps ensure that staff are able to participate in the identification of skill areas they would like to focus improvement efforts on. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Lead Agency supervisors perform a yearly Performance Review Assessment that includes reviews of the staff by the supervisor and self-evaluation reviews by all staff. In addition, all staff perform peer reviews periodically. Peer reviews include reviewing completed applications worked by co- workers. This practice deepens staff knowledge through the peer- review process and helps ensure that staff are able to participate in the identification of skill areas they would like to focus improvement efforts on. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Lead Agency supervisors perform a yearly Performance Review Assessment that includes reviews of the staff by the supervisor and self-evaluation reviews by all staff. In addition, all staff perform peer reviews periodically. Peer reviews include reviewing completed applications worked by co- workers. This practice deepens staff knowledge through the peer- review process and helps ensure that staff are able to participate in the identification of skill areas they would like to focus improvement efforts on. 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 may randomly select providers for audit of records or may base audits on findings in reports run on a regular basis. Program Integrity conducts the audit on behalf of the Lead Agency. Audits may include, but are not limited to, reviewing enrollment and other documentation, reviewing sign in and sign out sheets, and conducting an on-site visitation. This practice results in recoupment, when necessary, but more importantly allows the Lead Agency to identify areas where additional provider training is needed. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency may randomly select providers for audit of records or may base audits on findings in reports run on a regular basis. Program Integrity conducts the audit on behalf of the Lead Agency. Audits may include, but are not limited to, reviewing enrollment and other documentation, reviewing sign in and sign out sheets, and conducting an on-site visitation. This practice results in recoupment, when necessary, but more importantly allows the Lead Agency to identify areas where additional provider training is needed. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency may randomly select providers for audit of records or may base audits on findings in reports run on a regular basis. Program Integrity conducts the audit on behalf of the Lead Agency. Audits may include, but are not limited to, reviewing enrollment and other documentation, reviewing sign in and sign out sheets, and conducting an on-site visitation. This practice results in recoupment, when necessary, but more importantly allows the Lead Agency to identify areas where additional provider training is needed. 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 trains staff on policy and audit procedures during the staff's new hire orientation. Staff is notified of any policy or audit changes by official notification. Any additional training necessary for implementation of the changes is provided in staff meetings. This practice results in staff remaining current on all policies and implementation strategies. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency trains staff on policy and audit procedures during the staff's new hire orientation. Staff is notified of any policy or audit changes by official notification. Any additional training necessary for implementation of the changes is provided in staff meetings. This practice results in staff remaining current on all policies and implementation strategies. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency trains staff on policy and audit procedures during the staff's new hire orientation. Staff is notified of any policy or audit changes by official notification. Any additional training necessary for implementation of the changes is provided in staff meetings. This practice results in staff remaining current on all policies and implementation strategies. g. [x] Other. Describe the activity(ies): The Lead Agency through the Office of the Inspector General implements one telephonic and email hotline for reporting of waste, fraud, and abuse tips in all agency programs. This practice results in efficient routing of tips to all potentially impacted divisions to ensure a comprehensive response and data/program integrity. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency through the Office of the Inspector General implements one telephonic and email hotline for reporting of waste, fraud, and abuse tips in all agency programs. This practice results in efficient routing of tips to all potentially impacted divisions to ensure a comprehensive response and data/program integrity. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency through the Office of the Inspector General implements one telephonic and email hotline for reporting of waste, fraud, and abuse tips in all agency programs. This practice results in efficient routing of tips to all potentially impacted divisions to ensure a comprehensive response and data/program integrity. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Lead Agency through the Office of the Inspector General implements one telephonic and email hotline for reporting of waste, fraud, and abuse tips in all agency programs. This practice results in efficient routing of tips to all potentially impacted divisions to ensure a comprehensive response and data/program integrity. 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): Mississippi Department of Human Services, Office of Inspector General 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: Intentional program violations may be repaid under a repayment plan if the improper payment reaches the threshold amount of $1,000.00. Amounts identified through record review or other notification under $1,000 may be recovered through a one-time deduction from the next payment due. This practice results in the Lead Agency being able to hold providers accountable for incorrect funds received without placing undue financial burdens on providers. 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 and refer to the appropriate prosecutorial or collections authority. This process allows for a fair application of policies and avoids any opportunity of targeting providers when improper payments occur. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The Lead Agency provides notice of any alleged violations and an opportunity to dispute the allegations through the administrative hearing and appeals process. After the appeals process is exhausted or waived, the Lead Agency may enter a repayment plan in which the overpayment shall be repaid on a graduated (based on number of occurrences) monthly percentage rate. This practice results in allowing providers to still function as CCDF providers during a repayment process, maintaining the supply of CCDF providers available to parents. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Depending on the amount to be recouped and the circumstances included in the case, the Lead Agency may reduce payments made through the Child Care Payment Program to recover any improper payments. This practice results in allowing providers to still function as CCDF providers during a recoupment process, maintaining the supply of CCDF providers available to parents. 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 notify the Department of Revenue to offset any state funds from clients who are over 120 days delinquent on their overpayment as result of fraud or an improper payment from CCDF. These overpayments will be for the amount of $1,000 or over. 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: The Lead Agency through its Office of the Inspector General (OIG) monitors and collects improper payments. The OIG consists of Internal Audit and Program Integrity, which is made up of investigations and monitoring and claims and benefit recovery unit. This practice results in an impartial investigative process designed to apply policies uniformly and the Lead Agency recouping funding associated with improper payment, fraud, unintentional program violations, and intentional program violations. 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: Unintentional program violations may be repaid under a repayment plan if the improper payment reaches the threshold amount of $1,000.00. Amounts identified through record review or other notification under $1,000 may be recovered through a one-time deduction from the next payment due. This practice results in the Lead Agency being able to hold providers accountable for incorrect funds received without placing undue financial burdens on providers. 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 and refers to the appropriate prosecutorial or collections authority. This process allows for a fair application of policies and avoids any opportunity of targeting providers when improper payments occur. 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 provide notice of any alleged violations and an opportunity to dispute the allegations through the administrative hearing and appeals process. After the appeals process is exhausted or waived, the Lead Agency may enter a repayment plan in which the overpayment shall be repaid on a graduated (based on number of occurrences) monthly percentage rate. This practice results in allowing providers to still function as CCDF providers during a repayment process, maintaining the supply of CCDF providers available to parents. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Depending on the amount to be recouped and the circumstances included in the case, the Lead Agency may reduce payments made through the Child Care Payment Program to recover any improper payments. This practice results in allowing providers to still function as CCDF providers during a recoupment process, maintaining the supply of CCDF providers available to parents. 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 notify the Department of Revenue to offset any state funds from clients who are over 120 days delinquent on their overpayment as result of fraud or an improper payment from CCDF. These overpayments will be for the amount of $1,000 or over. 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: The Lead Agency through its Office of the Inspector General (OIG) monitors and collects improper payments. The OIG consists of Internal Audit and Program Integrity, which is made up of investigations and monitoring and claims and benefit recovery unit. This practice results in an impartial investigative process designed to apply policies uniformly and the Lead Agency recouping funding associated with improper payment, fraud, unintentional program violations, and intentional program violations. 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: Unintentional program violations may be repaid under a repayment plan if the improper payment reaches the threshold amount of $1,000.00. Amounts identified through record review or other notification under $1,000 may be recovered through a one-time deduction from the next payment due. This practice results in the Lead Agency being able to hold providers accountable for incorrect funds received without placing undue financial burdens on providers. 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 and refers to the appropriate prosecutorial or collections authority. This process allows for a fair application of policies and avoids any opportunity of targeting providers when improper payments occur. 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 provide notice of any alleged violations and an opportunity to dispute the allegations through the administrative hearing and appeals process. After the appeals process is exhausted or waived, the Lead Agency may enter a repayment plan in which the overpayment shall be repaid on a graduated (based on number of occurrences) monthly percentage rate. This practice results in allowing providers to still function as CCDF providers during a repayment process, maintaining the supply of CCDF providers available to parents. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Depending on the amount to be recouped and the circumstances included in the case, the Lead Agency may reduce payments made through the Child Care Payment Program to recover any improper payments. This practice results in allowing providers to still function as CCDF providers during a recoupment process, maintaining the supply of CCDF providers available to parents. 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 notify the Department of Revenue to offset any state funds from clients who are over 120 days delinquent on their overpayment as result of fraud or an improper payment from CCDF. These overpayments will be for the amount of $1,000 or over. 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: The Lead Agency through its Office of the Inspector General (OIG) monitors and collects improper payments. The OIG consists of Internal Audit and Program Integrity, which is made up of investigations and monitoring and claims and benefit recovery unit. This practice results in an impartial investigative process designed to apply policies uniformly and the Lead Agency recouping funding associated with improper payment, fraud, unintentional program violations, and intentional program violations. 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 Lead Agency may disqualify a client (through suspension or permanent disbarment) or place a client on probation for program violations. Any adverse decision may be appealed through the Lead Agency Administrative Review Process. 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 Lead Agency may disqualify a provider (through suspension or permanent disbarment) or place a provider on probation for program violations. Any adverse decision may be appealed through the Lead Agency Administrative Review Process. iii. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: If the Lead Agency finds: 1) that a client or provider has committed an intentional program violation, and 2) the improper payments due to the intentional program violation exceeds the threshold amount of $50,000, and 3) the accused fails to enter into a settlement agreement with the Lead Agency, the case may referred for criminal prosecution. 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: