Table of Contents
About TVFC Fraud and Abuse
As the complexity of immunizations and immunization-related programs grow, TVFC providers 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.
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 laws.
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 TVFC 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 costs to the Medicaid Program.
Oversight - The act of training, monitoring, and providing assistance to providers on TVFC 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. Providers terminated for fraud, abuse or non-compliance are dis-enrolled from Provider Education, Assessment, and Reporting (PEAR).
Waste - The careless, inefficient, or unnecessary use of TVFC Program resources.
Fraud or abuse can occur in many ways and some types of fraud and abuse are easier to prevent or detect than others. All TVFC providers should familiarize themselves with the examples below illustrating common practice errors that could result in fraud or abuse allegations. This list provides examples only, and should not be considered an exhaustive list of situations that would constitute fraud or abuse.
- 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 an inability to pay the administration fee
- Sending a parent or guardian to collections or charge additional fees for non-payment of a TVFC 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 the TVFC Program requirements may occur due to an unintentional lack of understanding of the 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 results in immediate referral for investigation of suspected TVFC fraud and abuse.
Fraud and Abuse Prevention
The TVFC Program actively works 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 the 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 TVFC Program or the responsible entity (DSHS HSR or LHD) via email, telephone, fax, or letter. Furthermore, newspaper articles and internet pages that promote potential fraudulent situations are investigated. The responsible entity (DSHS HSR or LHD) and DSHS quality assurance (QA) contractors must report all cases of alleged or suspected fraud or abuse. Reports received by the DSHS Immunization 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. The state Medicaid agency will conduct preliminary investigations and, as warranted, refer appropriate cases to the state’s Medicaid Fraud Control Unit following the Federal Regulatory scheme at 42 CFR section 455.15 and 42 CFR section 455.23.