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 in Ohio Benefits which is a person-centered system integrated with Medicaid, Supplemental Nutrition Assistance Program (SNAP), and TANF. As a result of this integration Child Care eligibility benefits from the matching criteria of the other programs for citizenship, income, address changes, etc. (TANF, SNAP, New Hires, SSA, PARIS). This allows us to not only benefit from the automated interfaces but also from the requirements of the other programs to report changes and complete renewals and recertifications. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Child Care eligibility is determined in Ohio Benefits which is a person-centered system integrated with Medicaid, SNAP, and TANF. As a result of this integration Child Care eligibility benefits from the matching criteria of the other programs for citizenship, income, address changes, etc. (TANF, SNAP, New Hires, SSA, PARIS). This allows us to not only benefit from the automated interfaces but also from the requirements of the other programs to report changes and complete renewals and recertifications. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: Child Care eligibility is determined in Ohio Benefits which is a person-centered system integrated with Medicaid, SNAP, and TANF. As a result of this integration Child Care eligibility benefits from the matching criteria of the other programs for citizenship, income, address changes, etc. (TANF, SNAP, New Hires, SSA, PARIS). This allows us to not only benefit from the automated interfaces but also from the requirements of the other programs to report changes and complete renewals and recertifications. 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: DCY has several reports that are produced that flag errors, these are reviewed and researched on a regularly scheduled basis. Examples of possible flag errors are as follows: •Are transactions being created on a day the family does not utilize care? •Are the transactions being created after the child(ren) have left for the day? •Are the transactions being created after the child(ren) has been dropped off for the day? •Are the transactions occurring on a day the provider is closed ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: DCY has several reports that are produced that flag errors, these are reviewed and researched on a regularly scheduled basis. Examples of possible flag errors are as follows: •Are transactions being created on a day the family does not utilize care? •Are the transactions being created after the child(ren) have left for the day? •Are the transactions being created after the child(ren) has been dropped off for the day? •Are the transactions occurring on a day the provider is closed 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: Enrollment and attendance are reviewed monthly in aggregate but are also able to be reviewed on the provider level. When attendance is recorded in ￿off hours￿ or we can see children are enrolled but not utilizing service it is an indication for DCY to determine if there is a barrier families are facing with the technology, a waitlist that is allowing enrollment not service, or any other issue or concern. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Enrollment and attendance are reviewed monthly in aggregate but are also able to be reviewed on the provider level. When attendance is recorded in ￿off hours￿ or we can see children are enrolled but not utilizing service it is an indication for DCY to determine if there is a barrier families are facing with the technology, a waitlist that is allowing enrollment not service, or any other issue or concern. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Enrollment and attendance are reviewed monthly in aggregate but are also able to be reviewed on the provider level. When attendance is recorded in ￿off hours￿ or we can see children are enrolled but not utilizing service it is an indication for DCY to determine if there is a barrier families are facing with the technology, a waitlist that is allowing enrollment not service, or any other issue or concern. 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 Ohio Department of Children and Youth audits provider records by identifying providers through data analytics. Reviews include comparing required attendance documentation to billing records. Additionally, reviews of eligibility records are conducted monthly and 75 cases are selected, a total of 900 case reviews are completed during the federal fiscal year. The following elements are reviewed: application/redetermination, qualifying head of household, residency, parental work/training status, qualifying child, qualifying care, qualifying care and provider arrangement, income requirements, and payment. Policy is copied on all error correspondence to the county agency. This is to ensure that overpayments are pursued, and statewide training can be developed based on error trend. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Ohio Department of Children and Youth audits provider records by identifying providers through data analytics. Reviews include comparing required attendance documentation to billing records. Additionally, reviews of eligibility records are conducted monthly and 75 cases are selected, a total of 900 case reviews are completed during the federal fiscal year. The following elements are reviewed: application/redetermination, qualifying head of household, residency, parental work/training status, qualifying child, qualifying care, qualifying care and provider arrangement, income requirements, and payment. Policy is copied on all error correspondence to the county agency. This is to ensure that overpayments are pursued, and statewide training can be developed based on error trend. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Ohio Department of Children and Youth audits provider records by identifying providers through data analytics. Reviews include comparing required attendance documentation to billing records. Additionally, reviews of eligibility records are conducted monthly and 75 cases are selected, a total of 900 case reviews are completed during the federal fiscal year. The following elements are reviewed: application/redetermination, qualifying head of household, residency, parental work/training status, qualifying child, qualifying care, qualifying care and provider arrangement, income requirements, and payment. Policy is copied on all error correspondence to the county agency. This is to ensure that overpayments are pursued, and statewide training can be developed based on error trend. 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 Ohio Department of Children and Youth audits provider records by identifying providers through data analytics. Reviews include comparing required attendance documentation to billing records. The results of this activity may include termination of the provider agreement and/or an issuance of an overpayment. This informs better practice by informing providers of their errors. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Ohio Department of Children and Youth audits provider records by identifying providers through data analytics. Reviews include comparing required attendance documentation to billing records. The results of this activity may include termination of the provider agreement and/or an issuance of an overpayment. This informs better practice by informing providers of their errors. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Ohio Department of Children and Youth audits provider records by identifying providers through data analytics. Reviews include comparing required attendance documentation to billing records. The results of this activity may include termination of the provider agreement and/or an issuance of an overpayment. This informs better practice by informing providers of their errors. 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 Ohio Department of Children and Youth hires staff with auditing backgrounds and trains them on specific audits and policies regarding the publicly funded child care program ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Ohio Department of Children and Youth hires staff with auditing backgrounds and trains them on specific audits and policies regarding the publicly funded child care program 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): The Ohio Attorney General's Office 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: If the total amount to be recovered is less than $100, it is not recovered due to administrative costs to be greater than the amount collected. If it is more than $100 the lead agency sends the provider an invoice for the amount due. Accounts Receivable collects any payments made. Those funds that are not collected within 30 days are turned over to the Ohio Attorney General's Office (AGO) for collection. The agency receives updates from the AGO. 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: DCY forwards all uncollected debt after 30-days of notification (considered delinquent) to the Ohio Attorney General's (AGO) Office for collection. The AGO performs the activities for the recovery of improper payments after these payments have been turned over for collection. The agency receives updates from the AGO. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Once the delinquent debt is forwarded to the Ohio Attorney General's Office, the AGO has the authority to administer payment plans and does. The agency receives updates from the AGO. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Once an overpayment or fraudulent payment is determined the payment is either set for a repayment through with reductions to the ongoing payments by the DCY Business Unit OR if the program is closed the payment can be assessed and submitted to the Attorney General for collection and remittance. 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 Ohio Department of Job and Family Services contains a specific unit that focuses solely on investigations and the collection of over payment. The unit is staffed by both investigators and auditors and supervisors that carryout the tasks including identifying the provider, investigating, collection of any identified overpayment and the termination of the provider agreement for publicly funded child care program. 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: If the total amount to be recovered is less than $100, it is not recovered due to administrative costs to be greater than the amount collected. If it is more than $100 the lead agency sends the provider an invoice for the amount due. Accounts Receivable collects any payments made. Those funds that are not collected within 30 days are turned over to the Ohio Attorney General's Office (AGO) for collection. Accounts Receivable collects provider payments. The agency receives updates from the AGO. 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: DCY forwards all uncollected debt after 30-days of notification (considered delinquent) to the Ohio Attorney General's (AGO) Office for collection. The AGO performs the activities for the recovery of improper payments after these payments have been turned over for collection. The agency receives updates from the AGO. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Once the delinquent debt is forwarded to the Ohio Attorney General's Office, the AGO has the authority to administer payment plans and does. The agency receives updates from the AGO. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: Once an overpayment or fraudulent payment is determined the payment is either set for a repayment through with reductions to the ongoing payments by the DCY Business Unit OR if the program is closed the payment can be assessed and submitted to the Attorney General for collection and remittance. 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: DCY has specific unit that focuses solely on investigations and the collection of over payment. The unit is staffed by both investigators and auditors and supervisors that carryout the tasks including identifying the provider, investigating, collection of any identified overpayment and the termination of the provider agreement for publicly funded child care program. 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: DCY notifies each county agency about identified county agency errors that resulted in improper payments. Each county agency has their own process for recovering improper payments. ii. [x] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: "DCY notifies each county agency about identified county agency errors that resulted in improper payments. Each county agency as their own process for recovering improper payments. For state agency errors, those funds that are not collected within 30 days are turned over to the Ohio Attorney General's Office for collection." iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Once an overpayment or fraudulent payment is determined the payment is either set for a repayment through with reductions to the ongoing payments by the DCY Business Unit OR if the program is closed the payment can be assessed and submitted to the Attorney General for collection and remittance. iv. [x] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: If/when there is a State state system generated improper payment, staff will work with the program on an acceptable reduced payment(s) to recoup or repay the funding. 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: Ohio Administrative Code 5101:2-16-07 details caretaker improper payments or misuse of publicly funded child care benefits. Process is as follows: *County agency shall calculate the overpayment resulting from an improper payment. *County agency shall notify the caretaker of the determined overpayment amount to be repaid using the JFS 01151, ""County Notice of Child Care Benefit Repayment Requirements for Caretakers. *County agency shall report payment received from caretakers in the county finance information system. *Caretaker shall sign the JFS 01151, ""County Notice of Child Care Benefit Repayment Requirements for Caretakers. *Caretaker shall make payments in accordance with the signed payment agreement. Failure of the caretaker to comply with the repayment agreement will result as follows: *County agency shall terminate child care benefits if the caretaker fails to enter into or comply with an agreement to repay a child care overpayment, and shall issue the appropriate hearing notice. *Caretaker remains ineligible for child care benefits until the caretaker complies with the agreement to repay the determined amount. Appeal Process: The JFS 01151, County Notice of Child Care Benefit Repayment Requirements for Caretakers, allows the caretaker two options. One, if the caretaker does not understand the action in the JFS 01151 they may contact the county representative listed on the JFS 01151 to request a conference. Two, if the caretaker does not agree with the action, they have the right to a state hearing. At a state hearing a hearing officer from the Ohio Department of Job and Family Services will make a final decision on the action. 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: DCY will terminate the provider agreement and assess an overpayment. The provider may not appeal the termination, and this prevents the provider from billing for publicly funded child care services. iii. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: Ohio Administrative Code 5101:2-16-07 Caretaker improper payment or misuse of publicly funded child care benefits describes that the county agency, in cooperation with the county prosecutor, shall develop and implement procedures for the investigation and/or prosecution of alleged child care caretaker fraud and the recovery of child care over payments from caretakers. If a caretaker has admitted or has been convicted of fraud by the court of law will result in the following: *County agency shall terminate child care benefits *Caretaker shall not be eligible for publicly funded child care benefits until full repayment has been made. 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: