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: Child Care eligibility is determined by using the same program, NEW HEIGHTS, that is used for eligibility for all other programs (SNAP, Medicaid, TANF, etc). VCI, New Hire, SS Administration, etc. are all used in this system as well. Therefore, all information is shared, including case comments and Special Investigation referrals for potential fraud violations. We have established 3 Childcare claims due to fraud totaling $28,557.35. One case has been sent for prosecution, but has not been adjudicated. In calendar year 2023, we did not establish any childcare fraud claims. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Child Care eligibility is determined by using the same program, NEW HEIGHTS, that is used for eligibility for all other programs (SNAP, Medicaid, TANF, etc). VCI, New Hire, SS Administration, etc. are all used in this system as well. Therefore, all information is shared, including case comments and changes that would affect the Child Care Program. SIU is currently researching our authority to collect on childcare claims due to client error. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: Child Care eligibility is determined by using the same program, NEW HEIGHTS, that is used for eligibility for all other programs (SNAP, Medicaid, TANF, etc). VCI, New Hire, SS Administration, etc. are all used in this system as well. Therefore, all information is shared, including case comments and changes that would affect the Child Care Program. There are no State laws that allow SIU to collect on Agency Error childcare claims. b. [ ] 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. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: 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: FCU reviews Provider attendance records and billings submitted by the Provider to ensure they’re in compliance with Child Care Rule He-C 6918. Findings are compiled into a report that is sent to BCDHSC for their review, prior to sending to the Provider. If intentional violations are found, they are sent to Special Investigations Unit (SIU) for further investigation. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: FCU reviews Provider attendance records and billings submitted by the Provider to ensure they’re in compliance with Child Care Rule He-C 6918. Findings are compiled into a report that is sent to BCDHSC for their review, prior to sending to the Provider. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: FCU reviews eligibility documents submitted by the client during their Quality Control reviews to ensure they meet requirements for the program and were processed accurately by worker. Findings are compiled into a report that is sent to BCDHSC for their review. 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: FCU reviews eligibility documents submitted by the client during their Quality Control reviews to ensure they meet requirements for the program and were processed accurately by worker. Findings are compiled into a report that is sent to BCDHSC for their review. If intentional violations are found, they are submitted to SIU for further investigation. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: FCU reviews Provider attendance records and billings submitted by the Provider to ensure they’re in compliance with Child Care Rule He-C 6918. Findings are compiled into a report that is sent to BCDHSC for their review, prior to sending to the Provider. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: FCU reviews eligibility documents submitted by the client during their Quality Control reviews to ensure they meet requirements for the program and were processed accurately by worker. Findings are compiled into a report that is sent to BCDHSC for their review. e. [x] Audit provider records. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: FCU reviews Provider attendance records and billings submitted by the Provider to ensure they’re in compliance with Child Care Rule He-C 6918. Findings are compiled into a report that is sent to BCDHSC for their review, prior to sending to the Provider. If intentional violations are found, they are sent to Special Investigations Unit (SIU) for further investigation. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: FCU reviews Provider attendance records and billings submitted by the Provider to ensure they’re in compliance with Child Care Rule He-C 6918. Findings are compiled into a report that is sent to BCDHSC for their review, prior to sending to the Provider. iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: f. [ ] Train staff on policy and/or audits. 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: 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): Client: Intentional error (fraud): SIU collects on fraudulent over payments of childcare under federal authority (45 CFR 98.60(i)). There is no threshold of $300; SIU does not have authority to not collect on fraud under $300, since this is mandated in federal regulations. Unintentional Error: Currently, SIU does not have legal authority to collect on childcare because of worker or client errors. There is no threshold of $300, this is for SNAP claims and does not pertain to childcare. The State Plan does indicate that there is collection on childcare for client errors but, in order to implement, BCDHSC would need to put something in rules or law to give SIU the authority to do so. However, RSA 167:17 may apply but we have not had time to review this law which covers all benefit programs. FCU & SIU are unaware of a ￿basic collection/notification letter￿, so we cannot verify if this is done or not, this will need further review. Results from investigations can be provided by SIU, they requested more information on this request, i.e. how far back does OCC need records on recoupments from? Provider: Unintentional Error: When it is determined that a Provider was overpaid funds during a FCU audit, due to an unintentional error, BCDHSC is responsible for recoupment; there is no minimum requirement. Included is the spreadsheet of the Provider audits completed in 2023 (provider audits were paused 10/2023 and have resumed as of 9/2024). Special Investigations Unit (SIU) investigates, establishes, and collects on all Family Assistance programs including Child Care pursuant to 45 CFR 98.60. SIU is independent of Policy Development and Eligibility Units, thus indiscriminately enforces eligibility infractions. SIU reports to Bureau of Program Integrity, under the Division of Program Qualify and Integrity. 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: Recovery for unintentional program violations is the same as for intentional program violations. DHHS has the Bureau of Program Integrity and Special Investigations Unit to which DHHS staff (BCDHSC or Bureau of Client Services) refers clients or providers when suspected of unintentional program violations. BPI works with the lead agency staff to investigate and determine whether or not an unintentional violation has occurred and develop an appropriate action to be taken, including the recovery of misspent funds. Referrals involve other law enforcement and prosecution authorities as appropriate. There is a claim threshold of $300.00. Claims that meet or exceed $300.00 will be pursued for collection. 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: Child care providers have 4 options for repayment plans. Option 1: Lump Sum Repayment: The provider can repay the entire amount of the claim in one lump sum. Option 2: Monthly Payment Arrangements: Due the first Monday of the Month, in the amount of $_________ ( we will allow the provider to choose based on their financial ability) Option 3: Recoupment via future Bridges N.H. Child Care Scholarship Payments. The overpayment will be deducted from the providers N.H. Child Care Scholarship payments issued by the Department. If you choose this option, you will need to indicate the amount that BCDHSC is to deduct from your weekly payments $_________. Option 4: Appeal. If the provider feels that this audit finding is incorrect, they can file an appeal. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Reduction of payments in subsequent months is the initial method utilized to recover funds due to unintentional program violations. In the event the provider continues to operate as a CCDF provider and a settlement amount identified, then the provider will have an agreed upon amount deducted from any subsequent CCDF provider payments until such time that the debt is fully recovered. NH has two programs currently on payment reduction plans. 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 Bureau of Program Integrity audits, investigates and collects payments due audit findings. We are still in the final stages of finalizing our procedure regarding the repayment procedure, but we are hoping in 2025 we will have a procedure and policy in place. The Bureau of Integrity has an agency audit manager and two agency auditors under the manager. This process has resulted in revision of process and procedures to recoup funds from improper payments. 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 Provider Relations Specialist adjusts claim payments that will benefit the family including improper charge amounts, decreased cost share changes, increased service levels or eligibility errors. The claims are adjusted on Monday mornings, by the Data Management team and are submitted on Monday afternoon by the providers. When the provider submits the adjusted claim timely then the payment will be sent on the next manifest date. Recovery for unintentional program violations is the same as for intentional program violations. DHHS has the Bureau of Program Integrity and Special Investigations Unit to which DHHS staff (BCDHSC or Bureau of Client Services) refers clients or providers when suspected of unintentional program violations. BPI works with the lead agency staff to investigate and determine whether or not an unintentional violation has occurred and develop an appropriate action to be taken, including the recovery of misspent funds. Referrals involve other law enforcement and prosecution authorities as appropriate. There is a claim threshold of $300.00. Claims that meet or exceed $300.00 will be pursued for collection. 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: 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. [ ] 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: ii. [ ]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: iii. [ ] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: iv. [x] Other. Describe the activities and the results of these activities based on the most recent analysis: The State of NH does not sanction clients under the NH Child Care Scholarship program. On May 23rd 2024, NH was cited due to the monitoring team not finding evidence that the Lead Agency has policies or processes to impose sanctions on clients that commit fraud. Additional time is needed beyond October 1, 2024 to implement this requirement. 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: