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 Department's eligibility system includes TANF, SNAP and Child Care Assistance programs, which allows the Department to match eligibility information across programs. In addition, the Child Care Assistance workers have access to the State Directory of New Hires and access to the Department's social security interface. These interfaces allow the Department to identify and prevent fraud or intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Department's eligibility system includes TANF, SNAP and Child Care Assistance programs, which allows the Department to match eligibility information across programs. In addition, the Child Care Assistance workers have access to the State Directory of New Hires and access to the Department's social security interface. These interfaces allow the Department to identify unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: The Department's eligibility system includes TANF, SNAP and Child Care Assistance programs, which allows the Department to match eligibility information across programs. In addition, the Child Care Assistance workers have access to the State Directory of New Hires and access to the Department's social security interface. These interfaces allow the Department to identify and prevent agency errors. 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: The Department's fiscal staff audit all child care invoices submitted by providers monthly or bi-monthly. Following the fiscal audit of the invoice, a different fiscal staff enters the billing information into the child care payment system and payment is generated. The process for review allows the Department to identify and prevent fraud or intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Department's fiscal staff audit all child care invoices submitted by providers monthly or bi-monthly. Following the fiscal audit of the invoice, a different fiscal staff enters the billing information into the child care payment system and payment is generated. The process for review allows the Department to identify unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Department's fiscal staff audit all child care invoices submitted by providers monthly or bi-monthly. Following the fiscal audit of the invoice, a different fiscal staff enters the billing information into the child care payment system and payment is generated. The process for review allows the Department to identify and prevent agency errors. 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 Department has an employee to conduct quality assurance of cases. The quality assurance staff reviews an average of 13 child care eligibility case files a month to ensure eligibility was determined correctly. In addition, the Department's Child Care Assistance Program supervisors review a minimum of three (3) cases per staff per month to ensure eligibility was determined correctly. The Department's Child Care Assistance Program Manager is responsible for reviewing all findings from the Child Care Assistance supervisors and quality assurance staff. These reviews allow the Department to identify and prevent fraud or intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Department has an employee to conduct quality assurance of cases. The quality assurance staff reviews an average of 13 child care eligibility case files a month to ensure eligibility was determined correctly. In addition, the Department's Child Care Assistance Program supervisors review a minimum of three (3) cases per staff per month to ensure eligibility was determined correctly. The Department's Child Care Assistance Program Manager is responsible for reviewing all findings from the Child Care Assistance supervisors and quality assurance staff. These reviews allow the Department to identify unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Department has an employee to conduct quality assurance of cases. The quality assurance staff reviews an average of 13 child care eligibility case files a month to ensure eligibility was determined correctly. In addition, the Department's Child Care Assistance Program supervisors review a minimum of three (3) cases per staff per month to ensure eligibility was determined correctly. The Department's Child Care Assistance Program Manager is responsible for reviewing all findings from the Child Care Assistance supervisors and quality assurance staff. These reviews allow the Department to identify and prevent agency errors. 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 Department's Child Care Licensing Program monitors all licensed programs and conducts two (2) visits per year following certification. A sampling of the provider records are reviewed at a visit to ensure compliance with the Rules for Certification of Family Child Care Home (FCCH), Family Child Care Center (FCCC), or Child Care Center (CCC). The Department's Child Care Assistance Program uses monitors to conduct annual inspection of licensed-exempt non-relative providers to ensure compliance with the provider requirements as defined in the Child Care Purchase of Service Rules. These inspections and monitoring allow the Department to identify and prevent fraud or intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Department's Child Care Licensing Program monitors all licensed programs and conducts two (2) visits per year following certification. A sampling of the provider records are reviewed at a visit to ensure compliance with the Rules for Certification of Family Child Care Home (FCCH), Family Child Care Center (FCCC), or Child Care Center (CCC). The Department's Child Care Assistance Program uses monitors to conduct annual inspection of license-exempt non-relative providers to ensure compliance with the provider requirements as defined in the Child Care Purchase of Service Rules. These inspections and monitoring allow the Department to identify and prevent unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Department's Child Care Licensing Program monitors all licensed programs and conducts two (2) visits per year following certification. A sampling of the provider records are reviewed at a visit to ensure compliance with the Rules for Certification of Family Child Care Home (FCCH), Family Child Care Center (FCCC), or Child Care Center (CCC). The Department's Child Care Assistance Program uses monitors to conduct annual inspection of licensed-exempt non-relative providers to ensure compliance with the provider requirements as defined in the Child Care Purchase of Service Rules. These inspections and monitoring allow the Department to identify and prevent agency 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 Department's Child Care Licensing and Child Care Assistance programs conduct ongoing training with all staff that includes review of rules, policy and procedure. The training is provided monthly, at a minimum, or more frequently if needed, and is conducted through email, webcam, or in person. Staff have the opportunity to collaborate with each other which allows for consistency and integrity of the program. These trainings allow the Department to identify and prevent fraud or intentional program violations. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: The Department's Child Care Licensing and Child Care Assistance programs conduct ongoing training with all staff that includes review of rules, policy and procedure. The training is provided monthly, at a minimum, or more frequently if needed, and is conducted through email, webcam, or in person. Staff have the opportunity to collaborate with each other which allows for consistency and integrity of the program. These trainings allow the Department to identify unintentional program violations. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: The Department's Child Care Licensing and Child Care Assistance programs conduct ongoing training with all staff that includes review of rules, policy and procedure. The training is provided monthly, at a minimum, or more frequently if needed, and is conducted through email, webcam, or in person. Staff have the opportunity to collaborate with each other which allows for consistency and integrity of the program. These trainings allow the Department to identify and prevent agency errors. 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 Department of Family Services Eligibility integrity Unit (EIU). b. Check and describe all activities, including the results of such activity, that the Lead Agency uses to investigate and recover improper payments due to fraud. Consider in your response potential fraud committed by providers, clients, staff, vendors, and contractors. Include in the description how each activity assists in the investigation and recovery of improper payment due to fraud or intentional program violations. Activities can include, but are not limited to, the following: i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: The Department sets the improper payment minimum dollar amount at $50.00. In instances where there are improper payments over the minimum, cases are referred to the EIU for investigation and collection. 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 EIU makes all necessary referrals (i.e. law enforcement, district attorney’s office) based on their investigation after a Child Care Assistance program case is referred. This ensures proper action is taken based on the activities of the case. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The EIU may enter into a repayment agreement following the investigation and determination of an improper payment. 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. [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 Department has an established Unit for investigations and collections of improper payments. The EIU investigates and collects on the following programs: SNAP, TANF, Low income Energy Assistance Program (LIEAP) and Child Care Assistance. The Unit resides with the Economic Security Division, Programs branch, which is led by a Senior Administrator and a Programs Administrator. The Unit is composed of a Manager, four (4) investigators/collections and one (1) accountant. viii. [x] Other. Describe the activities and the results of these activities: If a client is found guilty of an intentional program violation through a disqualification hearing, the client is sanctioned from receiving benefits for 12 months for the first violation, 24 months for a second violation and permanently for a third violation. The client has the opportunity to appeal the Department's decision through District Court. 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 Department sets the improper payment minimum dollar amount at $50.00. In instances where there are improper payments over the minimum, cases are referred to the EIU for investigation and collection. 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 EIU makes all necessary referrals (i.e. law enforcement, district attorney’s office) based on their investigation after a Child Care Assistance program case is referred. This ensures proper action is taken based on the activities of the case. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The EIU may enter into a repayment agreement following the investigation and determination of an improper payment. 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. [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 Department has an established Unit for investigations and collections of improper payments. The EIU investigates and collects on the following programs: SNAP, TANF, Low income Energy Assistance Program (LIEAP) and Child Care Assistance. The Unit resides with the Economic Security Division, Programs branch, which is led by a Senior Administrator and a Programs Administrator. The Unit is composed of a Manager, four (4) investigators/collections, one (1) Intake Specialist, and one (1) accountant. viii. [ ] Other. Describe the activities and the results of these activities: d. Does the Lead Agency investigate and recover improper payments due to agency errors? [ ] No. [x] Yes. If yes, check and describe all activities that the Lead Agency will use to investigate and recover improper payments due to agency errors. Include in the description how each activity assists in the investigation and recovery of improper payments due to administrative errors. Include a description of the results of such activity. i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: The Department sets the improper payment minimum dollar amount at $50.00. In instances where there are improper payments over the minimum, cases are referred to the EIU for investigation and collection. 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 EIU makes all necessary referrals (i.e. law enforcement, district attorney’s office) based on their investigation after a Child Care Assistance program case is referred. This ensures proper action is taken based on the activities of the case. iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: The EIU may enter into a repayment agreement following the investigation and determination of an improper payment. 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. [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 Department has an established Unit for investigations and collections of improper payments. The EIU investigates and collects on the following programs: SNAP, TANF, Low income Energy Assistance Program (LIEAP), Child Care Assistance, and Medicaid. The Unit resides with the Economic Security Division, Programs branch, which is led by a Senior Administrator and a Programs Administrator. The Unit is composed of a Manager, four (4) investigators/collections and one (1) accountant. 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: If a client is found guilty of an intentional program violation through a disqualification hearing, the client is sanctioned from receiving benefits for 12 months for the first violation, 24 months for a second violation and permanently for a third violation. The client has the opportunity to appeal the Department's decision through District Court. 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. [x] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: If appropriate, the EIU will refer cases to the district attorney’s office for prosecution based on their investigation after a Child Care Assistance program case is referred. 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: