Under what circumstances is a provider fraud referral made?
When processing an intentional overpayment to a provider, always review if the cause of the overpayment was due to deliberately misrepresenting facts. You can make a fraud referral if both the following two items apply, the:
Total established overpayment in WCAP is at least $5,000; Overpayment did not occur due to department error (such as double authorizations).
And at least one of the following applies, the:
Parent's signature appears to be forged; Provider billed for children not in care; Provider billed for services they did not provide (such as field trips).
Do not make a referral for fraud if any of the following apply, the:
Provider overbilled for care provided; Attendance records are incomplete or missing but the provider did care; Overpayment was partially due to department error (such as authorizing duplicate services).
How is a provider fraud referral made?
If you believe an overpayment or a combination of overpayments for one provider meets the above criteria refer the case and necessary documents to your DEL Central Office contact for review.
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Remember, DFI makes the determination of fraud so the original overpayment time period and minimum $5,000 amount used in these examples assumes the overpayment is within the three-year look-back period. |
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EXAMPLE 1
The provider billed 30 half-days when the attendance records show they were eligible for only 24 half-days. You can tell this has been going on for years and the total of the overpayment is over $5,000.
Is this an overpayment? YES
Is this a fraud referral? NO, this is poor billing and cannot be proven as deliberate fraud.
Refer to CPS intake line? Yes, if the records are incomplete. The licensor may be able to work with the provider on licensing issues. If the records are complete and the provider still billed incorrectly let the provider know they can contact the Department of Early Learning and ask about subsidy billing training.
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EXAMPLE 2
The provider billed for days you know a child did not attend. The provider shows you attendance records but you have conflicting information from the parent that the child was somewhere else on those days (such as the child was out-of-state, or with another provider, in the hospital, etc). The parent's signature does not look like any signatures you have on file for the case.
Is this an overpayment? YES
Is this a fraud referral? Possibly. Consider if the overpayment is at least $5,000.
Refer to CPS intake line? Yes, the licensor may be able to work with the provider on licensing issues.
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EXAMPLE 3
The provider did not make sure the parent signed in and out every day. Some days both signatures are there, some days only one signature is present. The total overpayment is over $5,000.
Is this an overpayment? YES
Is this a fraud referral? NO, this is poor attendance keeping and cannot be proven as deliberate fraud. Care was provided.
Refer to CPS intake line? Yes, the licensor may be able to work with the provider on licensing issues.
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EXAMPLE 4
The provider bills for children outside the age range on their license without a waiver.
Is this an overpayment? YES
Is this a fraud referral? NO. While our computer systems do not automatically catch these situations, the information is available within the department.
Refer to CPS intake line? Yes, the licensor may be able to work with the provider on licensing issues.
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EXAMPLE 5
A consumer reports they have three children who live in the home. All are eligible for and need child care. Later the AW discovers only 1 child used child care. The provider billed units for all 3 children.
Is this an overpayment? Yes. All payments made for the 2 children who did not use care are an overpayment. The overpayment should be assigned to the provider, either licensed or in-home/relative.
Is this a fraud referral? Possibly. Consider if the amount of the overpayment is at least $5,000.
Refer to CPS intake line? If the provider is licensed, yes.
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