Waste, Fraud, and Abuse

Waste, Fraud, and Abuse The Mississippi Department of Human Services has zero tolerance for the commission or concealment of acts of waste, fraud and abuse. Allegations of such acts will be investigated and pursued until the logical conclusion, including legal action when warranted. A. Definitions of Waste, Fraud and Abuse Waste involves the taxpayers not receiving a reasonable value for money in connection with any government funded activities due to an inappropriate act or omission by players with control over or access to government resources. Fraud is a type of illegal act of obtaining something of value through willful misrepresentation or a false representation of a material fact, whether by words or by conduct, by false or misleading allegations, or by concealment of that which should have been disclosed, which deceives another so that he acts, or fails to act to his detriment. Abuse involves behavior that is deficient or improper when compared with behavior that a prudent person would consider reasonable and necessary business practice given the facts and circumstances. Abuse also includes misuse of authority or position for personal financial interests or those of an immediate or close family member or business associate. Additional examples of Waste, Fraud and Abuse include but are not limited to: i. Misrepresenting household size or income ii. Falsifying application iii. Forging documents needed to complete intake iv. Omitting client information v. Creating ghost clients vi. Charging application fees vii. Former employee having access to software and system viii. Receiving kickbacks from vendor ix. Gross mismanagement or gross waste of funds B. General Reporting of Waste, Fraud and Abuse DCS encourages and enables, without retaliation or the fear of retaliation, employees, board of directors, vendors, volunteers, clients and the general public to disclose information believed to be waste, fraud, and abuse of CSBG & LIHEAP funding. Complaints of waste, fraud and abuse will be handled according to the process established in this policy. Anonymous reports may be submitted to the Office of Inspector General via 1-800- 299-6905 or by mail. MDHS Office of Inspector General 200 South Lamar Street Jackson, MS 39201 Providing specific occurrence details of suspected waste, fraud, and abuse will expedite investigative efforts. There is no requirement to submit identifying information from those who wish to report suspected waste, fraud, and abuse. Tips will be investigated in the order that they have been received with no preference given to those who provided identifying information. C. Agency Reported Suspected Waste, Fraud and Abuse 1) Reporting Suspected Client Fraud If an agency suspects that a client has committed waste, fraud or abuse, it is incumbent upon the agency to do their due diligence to review and provide documentation in support of their claim (documentation should include but is not limited to proof of misrepresentation or falsified document). All suspected fraud should be reported immediately. i. All claims must be submitted to DCS for review. Documentation should be uploaded into Virtual ROMA for DCS to complete a thorough review. Upon completion of DCS’ review, a response will be provided to the agency indicating if the claim has been substantiated, denied, or referred. If the claim cannot be substantiated or denied by DCS, the claim will be referred to the MDHS Office of Inspector General. ii. For substantiated claims, clients will be denied assistance following program penalties and will be coded as sanctioned in Virtual ROMA. 2) Reporting Suspected Representative of an Agency Fraud - Representatives of an agency include employees, board members, or volunteers. If it is suspected that a representative of an agency has committed waste, fraud or abuse, it is incumbent upon the individual reporting the fraud to provide documentation in support of their claim. Documentation should include but is not limited to proof of misrepresentation or falsified document. All suspected fraud should be reported immediately. i Suspected waste, fraud or abuse by an employee of an agency should be reported to their immediate supervisor. If the reporter’s supervisor is suspected of fraud, it should be reported to the Executive Director. If it is believed that the Executive Director may be committing fraud, the activity should be reported to the Board of Directors. The Division of Community Services should also be notified when an executive director has been reported to the Board. ii If it is believed that a member of the Board of Directors is involved, then the activity shall be reported to the Office of Inspector General at 1-800-299-6905 or by mail. The Division of Community Services should also be notified. MDHS Office of Inspector General 200 South Lamar Street Jackson, MS 39201 iii In the event that the agency is unable to support its claim but suspects that waste, fraud and abuse has taken place, the case must be referred to MDHS Office of Inspector General for investigation at 1-800-299- 6905 or email fraud@mdhs.ms.gov. 3) Reporting Vendor Suspected Waste, Fraud, or Abuse If it is suspected that a vendor has committed waste, fraud or abuse, it is incumbent upon the individual reporting the fraud to do their due diligence to provide documentation in support of their claim. Documentation should include, but is not limited to, proof of misrepresentation or falsified document. i. All claims must be submitted to DCS for review. Documents must be uploaded into Virtual ROMA for DCS to review. Upon completion of DCS’ review, a response will be provided to the agency indicating if the claim has been substantiated, denied, or referred. If the claim cannot be substantiated or denied by DCS, the claim will be referred to the MDHS Office of Inspector General. D. Penalties for Waste, Fraud and Abuse 1) A client who has committed waste, fraud and abuse will be subject to the following sanctions: i If it is the client’s first offense, the individual’s household will be ineligible for services for an entire year from the date of the decision and benefits will be recouped if necessary. Caseworkers must also code the client’s case as sanctioned in Virtual ROMA. • If the client is an Employee/Board Member or Volunteer of the agency they must also be terminated, removed from the board or deemed as ineligible to volunteer with any of the agency’s programs. ii If it is the client’s second offense, the individual’s household will be ineligible for services for twenty-four months from the date of the decision and benefits will be recouped if necessary. iii If it is the client’s third offense, the individual will be disqualified permanently from all DCS funded programs and is subject to prosecution and/or recoupment of any benefits provided, following due process as defined in agency regulations. 2) If a representative of the Agency has committed Waste, Fraud and Abuse shall be terminated or removed from the board. Additionally, they may be subject to prosecution and/or recoupment of any benefits provided, following due process as defined in agency regulations. 3) If a vendor has committed waste, fraud and abuse, the vendor will be suspended from participation and may be subject to prosecution and/or recoupment of any benefits provided, following due process as defined in agency regulations. 4) If there is an error that was caused by the subgrantee’s mistake, misrepresentation or fraud and it results in overpayment, the client, agency representative or vendor must not be held responsible for repayment. The subgrantee is responsible for repayment from non-federal funds.