Fraud and Abuse - Texas Vaccines for Children


Notice: The Texas Vaccines for Children Provider Manual is currently in the process of being updated. Please review the TVFC Policy Memo Updates to see if any updates apply to your specific situation.


Table of Contents


As the complexity of immunizations and immunization related programs grow, TVFC Program participants may become more vulnerable to unintentionally committing acts that could be construed as fraud and/or abuse. A working understanding of what constitutes fraud and abuse is critical for all persons working in the TVFC Program. Fraud and abuse, whether intentional or not, is subject to all federal fraud and abuse laws.


Definitions

Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program, [and/or including actions that result in an unnecessary cost to the immunization program, a health insurance company, or a patient]; or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

Oversight - The act of training, monitoring, and providing assistance to providers on program policies and procedures.

Enforcement - Identifying rules and policy violations and ensuring corrective action is taken.

Termination - The action taken when a provider is no longer eligible for the TVFC Program due to fraud, abuse, or non-compliance.

Waste - The careless, inefficient, or unnecessary use of public resources.


Examples

Fraud or abuse can occur in many ways and some types of fraud and abuse are easier to prevent or detect than others. TVFC Program providers should familiarize themselves with the examples below illustrating common practice errors that could result in fraud or abuse allegations.

  • Providing TVFC vaccine to non-TVFC eligible children
  • Selling or otherwise misdirecting TVFC vaccine
  • Billing a patient or third party for TVFC vaccine
  • Charging more than $14.85 for administration of a TVFC vaccine to an eligible child
  • Failing to meet licensure requirements for enrolled providers
  • Denying TVFC-eligible children TVFC vaccine because of parents' inability to pay the administration fee
  • Failing to implement provider enrollment requirements of the TVFC Program
  • Failing to screen for and document TVFC eligibility at every visit
  • Failing to maintain TVFC records for five years and comply with other requirements of the TVFC Program
  • Failing to fully account for TVFC vaccine
  • Failing to properly store and handle TVFC vaccine
  • Ordering TVFC vaccine in quantities or patterns that do not match provider profile or otherwise involve over-ordering of TVFC doses
  • Waste of TVFC vaccine

Failure to Comply with TVFC Requirements

When providers enroll in the TVFC program, they agree to comply with all the requirements of the program. Lack of adherence to the TVFC program requirements by an enrolled provider could lead to fraud and abuse of the TVFC program by that provider. Non-compliance with program requirements may occur due to an unintentional lack of understanding of the TVFC program requirements or the behavior may be intentional. If the non-compliance appears intentional and the provider has received financial benefits from the behavior, the situation would require immediate referral for investigation of suspected TVFC fraud and abuse.


Fraud and Abuse Prevention

TVFC will actively work with enrolled providers to help prevent fraud and abuse in the TVFC program. The best methods to prevent fraud and abuse are strong educational components discussed during the provider enrollment process and during TVFC compliance visits. Both occasions provide the opportunity to identify and prevent situations that may develop into fraud and abuse.


Reporting Fraud and Abuse

Suspected fraud or abuse can be reported to the DSHS Immunizations Unit, DSHS health service regions or local health departments via email, telephone, fax, or letter. Furthermore, newspaper articles and internet pages that promote potential fraudulent situations are investigated. DSHS health service regions, local health departments, and other contractors must report all cases of alleged or suspected fraud or abuse. Reports received by the DSHS Immunizations Unit in any form that merit further investigation will be referred to the Centers for Medicare and Medicaid Services (CMS), Medicaid Integrity Group (MIG) Field Office.

Last updated September 29, 2016