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: Nebraska currently shares data with the following programs: Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Low Income Housing Energy Assistance Program (LIHEAP), Aid to the Aged, Blind, and Disabled (AABD), and Social Services for the Aged and Disabled (SSAD), as all of these programs share the same eligibility system. This allows the Child Care program to have access to data that may be shared with another program that is not shared with the Child Care program. This helps prevent fraud and intentional program violations because it can show information that is required to be reported for the Child Care program but may have not been reported, such as over the SMI limit for income or moving to another state. Nebraska also uses the PARIS system to determine other state benefits to ensure that applicants are not already receiving Child Care in another state or that recipients don’t have cases in multiple states, such as those who live on the borders to other states. Nebraska also receives interface information from the Social Security Administration, Department of Labor, Child Support Enforcement, and Vital Statistics to help prevent fraud and intentional program violations by receiving information from these systems that may be required to be reported for the program but was not reported. Please note: The Child Care program only acts on information from these other programs if the recipient is required to report it or if it will benefit the household. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Nebraska currently shares data with the following programs: Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Low Income Housing Energy Assistance Program (LIHEAP), Aid to the Aged, Blind, and Disabled (AABD), and Social Services for the Aged and Disabled (SSAD), as all of these programs share the same eligibility system. This allows the Child Care program to have access to data that may be shared with another program that is not shared with the Child Care program. This helps unintentional program violations because it can show information that is required to be reported for the Child Care program but may have not been reported directly to the program, as we are a multiprogram system, such as over the SMI limit for income or moving to another state. Nebraska also uses the PARIS system to determine other state benefits to ensure that applicants are not already receiving Child Care in another state or that recipients don’t have cases in multiple states, such as those who live on the borders to other states. Nebraska also receives interface information from the Social Security Administration, Department of Labor, Child Support Enforcement, and Vital Statistics to help prevent unintentional program violations by receiving information from these systems that may be required to be reported for the program but was not reported. Please note: The Child Care program only acts on information from these other programs if the recipient is required to report it or if it will benefit the household. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: Nebraska currently shares data with the following programs: Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Low Income Housing Energy Assistance Program (LIHEAP), Aid to the Aged, Blind, and Disabled (AABD), and Social Services for the Aged and Disabled (SSAD), as all of these programs share the same eligibility system. This allows the Child Care program to have access to data that may be shared with another program that is not shared with the Child Care program. This helps prevent agency errors because it can show information that may have been reported to another program that is a change that will benefit the recipient for the Child Care program. Nebraska also uses the PARIS system to determine other state benefits to ensure that applicants are not already receiving Child Care in another state or that recipients don’t have cases in multiple states, such as those who live on the borders to other states. Nebraska also receives interface information from the Social Security Administration, Department of Labor, Child Support Enforcement, and Vital Statistics to help prevent agency errors to act on information that will benefit the recipient but may have not been directly reported to the program. 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: Nebraska runs monthly reports through the eligibility system that flag cases for clients who are receiving transportation when they should not be eligible for it, copayments that are being deducted from payments to the provider to make sure the co-payment has been deducted from the bill the provider submits to the Lead Agency, in-home providers that have billed over 180 hours in one month to confirm they are billing the correct hours, providers that have billed more days or partial days than are allowable in one month, and providers that make an excess of $250,000 per fiscal year. This allows monitoring and timely actions and/or corrections to be made. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Nebraska runs monthly reports through the eligibility system that flag cases for clients who are receiving transportation when they should not be eligible for it, copayments that are being deducted from payments to the provider to make sure the co-payment has been deducted from the bill the provider submits to the Lead Agency, in-home providers that have billed over 180 hours in one month to confirm they are billing the correct hours, providers that have billed more days or partial days than are allowable in one month, and providers that make an excess of $250,000 per fiscal year. This allows monitoring and timely actions and/or corrections to be made. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Nebraska runs monthly reports through the eligibility system that flag cases for clients who are receiving transportation when they should not be eligible for it, copayments that are being deducted from payments to the provider to make sure the co-payment has been deducted from the bill the provider submits to the Lead Agency, in-home providers that have billed over 180 hours in one month to confirm they are billing the correct hours, providers that have bill more days or partial days than are allowable in one month, and providers that make an excess of $250,000 per fiscal year. This allows monitoring and timely actions and/or corrections to be made. 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: CCDF Program Specialists and Resource Development staff will review billing and attendance records regularly to ensure program integrity. For example, a monthly report is generated for all providers that bill over 180 hours for in-home care. All claims that are submitted for that month over 180 hours are reviewed to ensure the provider is billing within the allowed hours. If the provider is not billing correctly, then calendars will be requested for review. Once these calendars are received, if the provider is overbilling, they will receive an overpayment in the amount they overbilled. CCDF Program staff also review a monthly report to check for any providers that have billed more days or partial days than allowable. This is flagged by providers that are billing more days or partial days than there are days in that given month. This prompts program staff to request attendance and billing records, and overpayments will be determined accordingly. The provider will also be given additional training by the Resource Development worker on correct billing practices to ensure they are billing correctly in the future and a letter is sent to the provider certifying that they have received this training. If the provider continues to overbill for future months, then further actions are taken at that time. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CCDF Program Specialists and Resource Development staff will review billing and attendance records regularly to ensure program integrity. For example, a monthly report is generated for all providers that bill over 180 hours for in-home care. All claims that are submitted for that month over 180 hours are reviewed to ensure the provider is billing within the allowed hours. If the provider is not billing correctly, then calendars will be requested for review. Once these calendars are received, if the provider is overbilling, they will receive an overpayment in the amount they overbilled. CCDF Program staff also review a monthly report to check for any providers that have bill more days or partial days than allowable. This is flagged by providers that are billing more days or partial days than there are days in that given month. This prompts program staff to request attendance and billing records and overpayments will be determined accordingly. The provider will also be given additional training by the Resource Development worker on correct billing practices to ensure they are billing correctly in the future and a letter is sent to the provider certifying that they have received this training. If the provider continues to overbill for future months, then further actions are taken at that time. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: CCDF Program Specialists and Resource Development staff will review billing and attendance records regularly to ensure program integrity. For example, a monthly report is generated for all providers that bill over 180 hours for in-home care. All claims that are submitted for that month over 180 hours are reviewed to ensure the provider is billing within the allowed hours. If the provider is not billing correctly, then calendars will be requested for review. Once these calendars are received, if the provider is overbilling, they will receive an overpayment in the amount they overbilled. CCDF Program staff also review a monthly report to check for any providers that have bill more days or partial days than allowable. This is flagged by providers that are billing more days or partial days than there are days in that given month. This prompts program staff to request attendance and billing records and overpayments will be determined accordingly. The provider will also be given additional training by the Resource Development worker on correct billing practices to ensure they are billing correctly in the future and a letter is sent to the provider certifying that they have received this training. If the provider continues to overbill for future months, then further actions are taken at that time. 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: Program Accuracy Specialists (PAS), frontline supervisors, and CCDF Program Specialists review several child care cases monthly. All cases that did not have a correct element are sent to the supervisor of the field staff worker to correct within 10 days of receipt. PAS, CCDF Staff, and trainers have monthly meetings discussing trends in policy questions and errors, which helps identify if additional training or policy/process tips are needed. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Program Accuracy Specialists (PAS), frontline supervisors, and CCDF Program Specialists review several child care cases monthly. All cases that did not have a correct element are sent to the supervisor of the field staff worker to correct within 10 days of receipt. PAS, CCDF Staff, and trainers have monthly meetings discussing trends in policy questions and errors, which helps identify if additional training or policy/process tips are needed. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Program Accuracy Specialists (PAS), frontline supervisors, and CCDF Program Specialists review several child care cases monthly. All cases that did not have a correct element are sent to the supervisor of the field staff worker to correct within 10 days of receipt. PAS, CCDF Staff, and trainers have monthly meetings discussing trends in policy questions and errors, which helps identify if additional training or policy/process tips are 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: CCDF Program Specialists and Resource Development staff will review billing and attendance records regularly to ensure program integrity. For example, a monthly report is generated for all providers that bill over 180 hours for in-home care. All claims that are submitted for that month over 180 hours are reviewed to ensure the provider is billing within the allowed hours. If the provider is not billing correctly, then calendars will be requested for review. Once these calendars are received, if the provider is overbilling, they will receive an overpayment in the amount they overbilled. CCDF Program staff also review a monthly report to check for any providers that have billed more days or partial days than allowable. This is flagged by providers that are billing more days or partial days than there are days in that given month. This prompts program staff to request attendance and billing records and overpayments will be determined accordingly. The provider will also be given additional training by the Resource Development worker on correct billing practices to ensure they are billing correctly in the future and a letter is sent to the provider certifying that they have received this training. If the provider continues to overbill for future months, then further actions are taken at that time. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: CCDF Program Specialists and Resource Development staff will review billing and attendance records regularly to ensure program integrity. For example, a monthly report is generated for all providers that bill over 180 hours for in-home care. All claims that are submitted for that month over 180 hours are reviewed to ensure the provider is billing within the allowed hours. If the provider is not billing correctly, then calendars will be requested for review. Once these calendars are received, if the provider is overbilling, they will receive an overpayment in the amount they overbilled. CCDF Program staff also review a monthly report to check for any providers that have billed more days or partial days than allowable. This is flagged by providers that are billing more days or partial days than there are days in that given month. This prompts program staff to request attendance and billing records and overpayments will be determined accordingly. The provider will also be given additional training by the Resource Development worker on correct billing practices to ensure they are billing correctly in the future and a letter is sent to the provider certifying that they have received this training. If the provider continues to overbill for future months, then further actions are taken at that time. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: CCDF Program Specialists and Resource Development staff will review billing and attendance records regularly to ensure program integrity. For example, a monthly report is generated for all providers that bill over 180 hours for in-home care. All claims that are submitted for that month over 180 hours are reviewed to ensure the provider is billing within the allowed hours. If the provider is not billing correctly, then calendars will be requested for review. Once these calendars are received, if the provider is overbilling, they will receive an overpayment in the amount they overbilled. CCDF Program staff also review a monthly report to check for any providers that have billed more days or partial days than allowable. This is flagged by providers that are billing more days or partial days than there are days in that given month. This prompts program staff to request attendance and billing records and overpayments will be determined accordingly. The provider will also be given additional training by the Resource Development worker on correct billing practices to ensure they are billing correctly in the future and a letter is sent to the provider certifying that they have received this training. If the provider continues to overbill for future months, then further actions are taken at that time. 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: Eligibility staff are trained on program requirements at new hire and as needed by Supervisory staff. Eligibility staff are also trained by CCDF Program Staff when there are any major program changes, such as updates to policies or procedures. Resource Development staff also receive new employee training and ongoing training as needed. Audit results are shared with all staff that works the Child Care Subsidy program so they are aware of what audit issues have become larger concerns. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Eligibility staff are trained on program requirements as new hires and as needed by Supervisory staff. Eligibility staff are also trained by CCDF Program Staff when there are any major program changes, such as updates to policies or procedures. Resource Development staff also receive new employee training and ongoing training as needed. Audit results are shared with all staff that works the Child Care Subsidy program so they are aware of what audit issues have become larger concerns. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Eligibility staff are trained on program requirements at new hire and as needed by Supervisory staff. Eligibility staff are also trained by CCDF Program Staff when there are any major program changes, such as updates to policies or procedures. Resource Development staff also receive new employee training and ongoing training as needed. Audit results are shared with all staff that works the Child Care Subsidy program so they are aware of what audit issues have become larger concerns. 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): The Lead Agency has a Special Investigations Unit that reviews and pursues any potentially fraudulent activity. There is also an Overpayment team that referrals are sent to for any suspected overpayments. Once the Overpayment team determines if there is an overpayment if the case meets the definitions of fraudulent activity a referral is then made to the fraud departments. The Issuance and Collections Department also reviews and determines provider overpayments for the Lead Agency. 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. [ ] 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: 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: If a CCDF provider has an improper payment due to an unintentional program violation, the Lead Agency will set up a payment plan with the provider if they are not active. They have the option to pay in full or make payment arrangements. Ideal results of this would be a full recoupment of the full overpayment. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: If a CCDF provider has an improper payment due to an unintentional program violation, the Lead Agency will reduce the subsequent payments made to the provider by a percentage each month until the improper payment has been paid in full. If the provider fails to make payment arrangements, the entire unintentional program violation amount will be taken at the next billing cycle. Ideal results of this would be a full recoupment of the full overpayment amount. 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: The Issuance and Collections unit is made up of Fiscal Compliance Analysts who will investigate the unintentional program violations, decide, and attempt to collect an overpayment. Establishing this team has increased the number of cases reviewed and the recoupment of overpayments. 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. [ ] 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: 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: If a CCDF provider has an improper payment due to an unintentional program violation, the Lead Agency will set up a payment plan with the provider if they are not active. They have the option to pay in full or make payment arrangements. Ideal results would be a full recoupment of the full overpayment amount. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: If a CCDF provider has an improper payment due to an unintentional program violation, the Lead Agency will reduce the subsequent payments made to the provider by a percentage each month until the improper payment has been paid in full. If the provider fails to make payment arrangements, the entire unintentional program violation amount will be taken at the next billing cycle. Ideal results would be a full recoupment of the full overpayment amount. 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: The Issuance and Collections unit is made up of Fiscal Compliance Analysts who will investigate the unintentional program violations, decide, and attempt to collect an overpayment. Establishing this team has increased the number of cases reviewed and the recoupment of overpayments. 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? [x] No. [ ] 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. [ ] 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: 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. [ ] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: 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: Overpayments caused by recipient error will be recouped or collected by any lawful means. When the overpayment appears to be the result of fraud, the case will be referred to the Special Investigations Unit, Central Office, or the Omaha Special Investigations Unit for Omaha cases. An individual who is found to have committed an intentional program violation is disqualified from receiving Child Care Subsidy Services. If an individual is found to have committed an intentional program violation, a period of disqualification must be imposed. The disqualification applied to the individual found to have committed the intentional program violation and the household. These penalties will also be imposed if the individual is found by a court to have committed an intentional program violation. The period will be determined by the Department after an administrative hearing, or without a hearing, if the individual waives their right to a hearing. The period of disqualification is: 1. For a first violation, the individual is disqualified for one year; 2. For a second violation, the individual is disqualified for two years; and 3. For a third violation, the individual is permanently disqualified. A client has 90 days to file an appeal if they do not agree with the actions taken to determine an overpayment or intentional program violation. The appeal must be filed in writing to the hearing office or on a DA-6 (Request for Fair Hearing) form provided by the Lead Agency. 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: If a CCDF provider breaches their Subsidy agreement, they may lose the ability to be a CCDF provider for 10 years. CCDF providers do not have the right to appeal Department decisions, except when an overpayment has been assessed or the termination or denial was the result of a criminal background check. If the provider disagrees with a Department decision other than an overpayment or background check, they can request their case to be re-evaluated by the Lead Agency. If the Lead Agency finds that the decision was made in error, the Lead Agency will overturn the decision. If the provider disagrees with the Department’s determination regarding an overpayment or background check, the provider has 30 days from the date of mailing to appeal. iii. [ ] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: 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: