Fraud PowerPoint 3_03_2015.pdf · •“Fraud” is an intentional deception, omission, or...

Fraud

Early Learning Coalition of Northwest Florida 3-03-2015

Definition

• “Fraud” is an intentional deception, omission, or misrepresentation made by a person with knowledge that the deception, omission, or misrepresentation may result in unauthorized benefit to that person or another person, or any aiding and abetting of the commission of such an act. The term includes any act that constitutes fraud under applicable federal or state law.

Relevant Florida Statutes

• Florida Statutes 1002.82 – Office of Early Learning; powers and duties

• Florida Statutes 1002.91 - Investigations of fraud or overpayment; penalties

• Florida Statutes 414.39 – Fraud

• Florida Statutes 414.411 – Public assistance fraud

Fraud Statutes & New Statewide SR Provider Contract

• Fraud statutes are referenced in the new Statewide SR Provider Contract

• The Office of Early Learning has made the New Statewide SR Provider Contract available for your review (see Coalition BLAST Wednesday Feb 25th)

Paragraphs 63 and 64 of the New Statewide SR Provider Contract

• Not here to present or answer questions regarding the new the contract

• Simply want to show you that the fraud language we’ve discussed the last 3 months is in the new Statewide SR Provider Contract

New Statewide SR Provider Contract Paragraph 63 – Fraud (a) – (e)

• a. Anti-Fraud Plan

• Provider agrees to comply with the anti-fraud plan established by Coalition in accordance with s. 1002.91, F.S.

• b. Payment Certificate Fraud Investigation

• In accordance with s. 1002.82(6)(d), F.S., if it is determined that Provider has given any cash or other consideration to the beneficiary in return for receiving a payment certificate, Coalition or its fiscal agent shall refer the matter to the Department of Financial Services pursuant to s. 414.411, F.S., for investigation.

• c. Suspension for Suspected Fraud

• In accordance with s. 1002.91(4), F.S., Coalition may suspend or terminate Provider from participation in the school readiness program when it has reasonable cause to believe that Provider has committed fraud. Provider may request a review of Coalition’s determination to suspend Provider as described in paragraph 64.

• If suspended, Provider shall remain suspended until the completion of any investigation by the Office of Early Learning, the Department of Financial Services, or any other state or federal agency, and any subsequent prosecution or other legal proceeding.

• d. Termination Fraud

• In accordance with s. 1002.91(5), F.S., if Provider, or an owner, officer, or board director thereof, is convicted of, found guilty of, or pleads guilty or nolo contendere to, regardless of adjudication, public assistance fraud pursuant to s. 414.39, F.S., or is acting as the beneficial owner for someone who has been convicted of, found guilty of, or pleads

• guilty or nolo contendere to, regardless of adjudication, public assistance fraud pursuant to s. 414.39, F.S., the Coalition shall refrain from contracting with, or using the services of, Provider for a period of five (5) years.

• In addition, Coalition shall refrain from contracting with, or using the services of, any provider that shares an officer or board

• director with a provider that is convicted of, found guilty of, or pleads guilty or nolo contendere to, regardless of adjudication, public assistance fraud pursuant to s. 414.39, F.S. for a period of five (5) years.

• e. Termination for National Disqualification

• In accordance with s. 1002.91(7), F.S., if Provider is placed on the United States Department of Agriculture National Disqualified List, Coalition must terminate this Contract for cause.

• In addition, if Provider shares an officer or board director with a provider that is on the

• United States Department of Agriculture National Disqualified List, Coalition must terminate this Contract for cause.

New Statewide SR Provider Contract

Paragraph 64 – Due Process Procedures.

• Provider may request a review of determinations made by Coalition under this Contract. Reviews will be conducted in accordance with Exhibit 5: Due Process Procedures.

• While a request for a review is being examined, Provider is not required to implement corrective action.

• In accordance with s. 1002.82(2)(m), F.S., Provider may not offer any School Readiness services while a request for a review regarding termination of provider’s School Readiness Contract is being examined.

Attendance Documentation

• Brief review

• Specific areas of concern

Poor Business Practices

• Errors, questioned and/or disallowed costs related to the submission of an inaccurate invoice for School Readiness services have the potential to be interpreted as an intentional misrepresentation to receive unauthorized payment for School Readiness services, which may result in a suspected fraud referral to the Office of Early Learning for further investigation.

Review – Completion of SR Provider Monthly Attendance Records/Invoice • All documentation must be legible. • White-out must not be used anywhere on the

forms. If an error is made, Providers must mark through the error and write-in the correct entry and initial.

• Attendance Records must be completed in INK. • Attach Extraordinary Circumstance Absentee

Documentation . • Copy of Rilya Wilson Absence Documentation

Form, as applicable

Legend to Complete Attendance Invoice

• Use of approved Attendance Codes is required. Failure to use approved Attendance Codes as listed on the Legend of the Enrollment/Attendance Certification School Readiness Form (Attendance Roster) may result in nonpayment:

• X = Enrolled/Present. Child was in attendance. • E = Excused Absence: Child is absent and is approved

for payment for no more than three (3) days and no written documentation is required. Allowed 3 excused absences (E’s) per month.

• A = Authorized Absence Beyond 3 Days. Child is absent beyond three (3) days. Written documentation is required by the parent justifying the excessive absences for up to an additional seven (7) days. The Coalition will determine if the documentation is acceptable and provides approved authorization for payment.

• NOTE • The total monthly reimbursed absences to a School Readiness

Provider may not exceed a total of ten (10) days per month. This can include three (3) E’s with no documentation plus seven (7) A’s with approved documentation or a total of ten (10) A’s with approved documentation.

Extraordinary Circumstances

• Examples of Extraordinary Circumstances and documentation include the following:

– Hospitalization of the child or parent with appropriate documentation (i.e. statement from the hospital and/or physician stating patient’s proper name, admit date, release date);

– Illness of child documented by doctor’s note with the child’s proper name, date the child was seen, the date child is allowed to return to school and signature of the physician/physician’s staff;

– Documented illness requiring home stay;

– Death in the immediate family with appropriate documentation (i.e. obituary, death certificate, that lists parent and/or child’s name);

– Court ordered visitation with appropriate documentation (i.e. court order with dates of visitation reflecting dates absent); or

– Unforeseen documented military deployment or exercise of the parent (i.e. deployment orders).

• N = Enrolled, Non-Reimbursable: This code is used for holidays, excused absences (E’s) more than three (3) days or authorized absences (A’s) more than ten (10) days, or any other closure/absence not allowable by federal, state or Coalition guidelines

• T = Terminated: This code is used to indicate that a child has

withdrawn, is no longer receiving services through the Coalition, or has been terminated from the School Readiness program. School Readiness Provider should place a “T” on the day AFTER the child’s last day of attendance.

• If Coalition staff cannot determine what a mark is, an E will be

given. If the child has more than three (3) E’s the School Readiness Provider will not be paid for undeterminable days.

• LEAVE the column at end of Attendance Roster BLANK. COALITION MUST COMPLETE the DAYS ATTENDED Column on the Enrollment/Attendance Certification for School Readiness (Attendance Roster).

• NOTE: The child’s Eligibility Expiration and/or Re-determination date is

printed in the right hand column of the Attendance Roster (Enrollment/Attendance Certification for School Readiness). If the parent does not contact the Coalition to renew their eligibility before that date, School Readiness care provided past the expiration or re-determination date will NOT BE REIMBURSED.

• An asterisk (*) appears to the right of any child's name whose parent's

REDETERMINATION date is due during the current month on the School Readiness Attendance Roster (Enrollment/Attendance Certification).

SR Provider Contract FY 2014-15

School Readiness Provider Contract FY 2014-2015 Section IV Provider Responsibilities Paragraph 13 Child Enrollment Provider agrees to enroll children for the School Readiness program only with written authorization from Coalition which will be provided in the form of a child care certificate. Provider shall not enroll a child into its SR program without a child care certificate. Additionally, Provider understands that it will not be reimbursed for services provided to a child beyond the service begin and end date identified by Coalition on the child care certificate. Provider also agrees to serve children enrolled into its School Readiness program according to the schedule established on the child care certificate.

Discrepancies in Attendance

• Claiming “X” when child is absent

• Claiming more than 3 E’s

• Claiming 3 E’s and 2 A’s (No absence documentation)

• Claiming E for BG1 Child – no Rilya Wilson Absence Documentation Form

• Claiming A’s when appropriate code is an E (possible confusion with VPK coding)

• Claiming X’s beyond the service begin & end date

• White out used on:

• Enrollment/Attendance Certification (Rosters)

• Sign-in/out Sheets

• Rilya Wilson Documentation of Absence forms

Discrepancies in Attendance

• Children marked absent on CCFP attendance but marked present on the SR attendance and signed in and out.

• Children marked present on CCFP attendance but marked absent on the SR attendance and not signed in and out.

Perfect Attendance

• 100% enrolled/present for the month of November

• 100% enrolled/present for the month of December

• 100% signed in/out – even on holiday that center was closed

Same Time Every Day

• Child signed in at the same time every day and signed out at the same time every day.

– This is not an accurate recording of time.

Signatures Need Further Investigation

• Parent’s name is misspelled

• Signed three different ways on same sheet

• Slanted in opposite direction

• Simply printed

“BUS” is not an acceptable signature

• Child signed in by “BUS”

- This is not an acceptable signature

School-age Children who are Authorized for Before and After care

• Signed in by the parent/guardian with time and signature in the morning when the child is brought to the SR Provider

• Signed out by the SR Provider with time, signature and “BUS” when the child catches the bus for school

• Signed in by the SR Provider with time, signature and “BUS” when the child returns from school

• Signed out by the parent/guardian with time and signature when the child is picked up for the day

Children Enrolled for After School Care Only

• Signed in by SR Provider with time and Signature and “BUS”

• Signed out with time and signature by the parent/guardian when the child is picked up for the day

Providers who Transport Children Enrolled in their Facility

• Required to have the van/bus driver sign the children in with time and signature when they pick the children up

• Required to have the parent/guardian sign the children out with time and signature when taken off the van/bus when the children are transported back home.

IS YOUR INVOICE ACCURATE?

• For the last 3 months, was your invoice accurate?

• If NO, WHY NOT?

• What steps did you put in place to address/correct the deficiency?

• How many providers are confident the invoice submitted today is accurate?