Client Compliance Process Logging and Investigating Complaints of - - PDF document

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Client Compliance Process

Logging and Investigating Complaints

• f Client Fraud and Abuse

Agenda

• Introduction to Client Compliance in the

MI-WIC environment C C

• Introduction to MI-WIC Compliance

Screens

• How to log, investigate, and document

complaints of client fraud and abuse

• How to generate a client Compliance
• How to generate a client Compliance

Letter

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Agenda

• The Sanctioning process
• How to initiate the client restitution

( t) (repayment) process

• Revised client compliance policy, MI-

WIC Policy 9.01

• Using the Client Compliance Log Report

in the MI-WIC System in the MI WIC System

• Using the Client Complaint and

Investigation Summary Report

Compliance-Introduction

• After a brief discussion defining client

fraud and abuse, we will demonstrate how to log a complaint of fraud and how to log a complaint of fraud and abuse.

• Following the logging session, WIC staff

who do not participate in fraud and abuse investigations may be excused.

• Please make note of your questions as

we go. There will be a Q and A session following the presentation.

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Compliance Policies

• Old WIC Policy

10.02 and Exhibits 10.02A, B, C, D, E,

• Revised to MI-WIC

Policy 9.01 Client Compliance and F, and G. p Exhibits 9.01A and 9.01B.

• Should be effective
• Sept. 24, 2010, with

the MI-WIC Release 4.6.

Compliance Policies

• Old WIC Policy

10.03 Employee Compliance

• Continue to use old

WIC Policies until revisions of these Compliance

• Old WIC Policy

10.04 Employee Conflict of Interest revisions of these policies have been completed and approved by the USDA regional

• ffice.

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What is a Client Compliance Complaint?

• Any complaint which alleges actual or

potential client fraud and abuse, such p as:

• Misrepresentation of eligibility
• Altering EBT benefits
• Return of WIC foods to vendor for

unapproved items, credit or cash

Fraud and Abuse cont.

• Buying, exchanging, or selling WIC

foods B i h i lli WIC EBT

• Buying, exchanging or selling WIC EBT

card

• Use of another person’s EBT card

except as authorized proxy

• Theft of EBT card

Theft of EBT card

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Fraud and Abuse cont.

• False reporting of lost EBT card or

benefits

• Allowing unauthorized person to use
• Allowing unauthorized person to use

EBT card

• Verbal abuse of WIC staff, vendor staff

and/or other WIC clients

• Collusion with staff to obtain benefits

Collusion with staff to obtain benefits improperly

Fraud and Abuse cont.

• Dual participation
• Failure to repay previous claim
• Physical abuse, actual or threatened
• Destruction of property

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Agency Responsibilities

• The Agency is responsible for

educating clients about the expectations and requirements of the WIC Program and requirements of the WIC Program.

• Clients must be notified of actions which

constitute WIC fraud and abuse before benefits are issued to them. This Is done when they sign the WIC Client Agreement.

Receiving Complaints

• Anonymous phone calls or letters
• Report from WIC Vendors, employees,

clients or the general public clients, or the general public

• Actual or threatened verbal or physical

abuse

• Potential Dual Participation evidenced

by same client with overlapping benefits by same client with overlapping benefits and dual redemption verified in EPPIC

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Receiving Complaints

• Public information reports, i.e.

newspaper/internet information suggesting potential client violation.

• Craig’s List

Other Complaints

• Customer Service Complaints

Create your own system for logging

• Vendor Complaints - Refer to Vendor

Hotline:1-800-CALL-WIC

• These types of complaints are not

put in MI-WIC System

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Logging a Client Fraud and Abuse Complaint Complaint

Logging a Complaint

• Revised MI-WIC Policy 9.01 states in

Guidance, “Local Agency Coordinator may determine who will be responsible may determine who will be responsible for obtaining details of fraud and abuse allegations (i.e., who may take calls and enter MI-WIC data).”

• Potential for complaints to be

“ ” f considered “hearsay” if not logged appropriately.

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Logging a Complaint

• Once the Local Agency has determined

how the client complaints shall be logged they should be documented in logged, they should be documented in the MI-WIC System according to Local Agency procedure.

• It is not mandatory at this

time that you write a formal policy regarding how complaints are logged.

Logging a Complaint

• From the

Miscellaneous Drop Down,

Add Complaint

select Add Complaint.

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Logging a Complaint

• The Complaints

Screen will be superimposed

• n the Search

Screen.

• Case number is

automatically assigned by the system.

• Case number
• Case number,

Date, and your name will automatically populate into the log.

Logging a Complaint

• When a new

complaint is logged, the system will the system will automatically assign the case number.

• The date the

complaint is logged complaint is logged is the “Received Date”.

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Logging a Complaint

• When

“Complaint Method” button is clicked, a drop down will appear

• ffering choices
• f Letter, Other,

Phone, or Mail.

• Select one of

Select one of those to describe how you received the complaint.

Logging a Complaint

• When you are

logged into the system and you enter a complaint, your name will appear in the “Complaint “Complaint Recipient” field.

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Logging a Complaint

• “Type of

Complainant” field is used to field is used to describe who made the complaint. Select one of the choices from this drop down field.

Logging a Complaint

• Select your

Local Agency from the “LA” drop down field.

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Logging a Complaint

• Select which

clinic the client or authorized person is enrolled in.

Logging a Complaint

• In the

“Family/ Client ID” Client ID” drop down, select the description that best fits the person the person the complaint is about.

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Logging a Complaint

• Enter the

“Family/Client ID”, the “First Name” and “Last Name” of the person whom the complaint is complaint is logged about.

Logging a Complaint

• In the “Notes”

field, enter as much information about this case as you can.

• For example:

what is being alleged, what are the details around this case?

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Logging a Complaint

• Now that we have taken a look at the

fields on the Complaint screen, let’s see what a fully logged complaint looks like.

Logging a Complaint

• Complete all

information to the best of your ability. y

• If any information

was left out or entered incorrectly, the Compliance Investigator can g go back into this screen from the Compliance Investigations Screen to correct.

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Logging a Complaint

• Upon saving

the logged complaint, a p pop up screen will ask you if you would like to send a message to the LA C di t LA Coordinator regarding this complaint?

Logging a Complaint

• When you click on “Yes”, a message

will appear in the LA Coordinator’s Message Board Message Board.

• Agencies where staff other than LA

Coordinator are logging complaints may also write a procedure requiring their staff members to notify them via phone y p

• r e-mail.

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Logging a Complaint

• By clicking on

the “Complaint” jelly bean at the bottom of the Compliance Investigations Screen, the Compliance Investigator can make changes to the original complaint.

Thank you for view ing this portion of the Client Compliance Webcast!

• Staff who do not conduct Compliance

Investigations may now go back to clinic.

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Conducting Compliance Investigations Investigations

Compliance Letters, Sanctioning, Restitution Payments

Local Agency Coordinators/Compliance Investigators

• May receive complaint notices in

May receive complaint notices in several ways.

• Message on Message Board when

another staff member or State staff has logged a complaint against one of your clients clients.

• Staff members may call or e-mail you to

notify you that a new complaint has been logged into the system.

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Compliance Investigations

• May access

complaints by going to the “Case Number” drop Number drop down on the Compliance Investigations Screen.

• All complaints

logged for your logged for your agency will appear in this drop down.

Compliance Investigations

• You may also

run a Client Compliance p Log Report for your agency by clicking on “Reports”, “Participation”, “Cli t

Participation Client Compliance Log

“Client Compliance Log”.

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Compliance Investigations

• This report will

give you a list of the active complaints logged p gg for your agency by agency, clinic and date.

• Run this Report

by Local Agency at least once a month to monitor the status of complaints in your Local Agency.

Compliance Investigations

• Refer to revised MI-WIC Policy 9.01 for

detailed steps on completing a compliance investigation compliance investigation.

• All actions taken during the investigation

should be documented in the “Investigation Notes” field on the Compliance Investigations Screen.

• Dates are important and sensitive due

to Fair Hearing Procedures which could be requested by the complainant.

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Compliance Investigations

• To access the

“Compliance Investigations”

Compliance Investigations

Miscellaneous

g Screen, click

• n the

Miscellaneous drop down, and click on “C li “Compliance Investigations”

Compliance Investigations

• To document

an investigation investigation go to the Compliance Investigations screen, find the case number in drop down, and Click “Go”.

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Compliance Investigations

• You may also

enter the case number if you know it and click on “Go” to populate the details regarding this case.

Compliance Investigations

• After clicking

“Go” information entered on the Complaint Log will automatically populate into the screen the screen.

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Compliance Investigations

• Now let’s take a look at the fields on the

“Compliance Investigations” screen.

Compliance Investigations

• The first field
• n this

screen is the “C “Case Number” drop down field.

• All of the

cases logged gg in from your Local Agency should appear in this drop down.

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Compliance Investigations

• Or you may

enter the case number in the “Or” field and click “Go” to populate the data for this case on the screen.

Compliance Investigations

• “Current Case

Number”, Family or Cli t ID” Client ID”, “LA”, “Received Date”, “Clinic”, and “Notes” fields will all t ti ll automatically populate from the Complaint page information.

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Compliance Investigations

• By clicking on

the “Add” button, “Investigation Notes” can be entered.

• The date of the

note will automatically populate as well as the name of the person logged into the system system.

• A pop-up dialog

box will appear for writing notes when you click in the “Notes” field.

Compliance Investigations

• In the “Violation

Type Alleged” field, when you click on the “Add” click on the Add button, a drop down will appear.

• Choose the

correct Violation Type and click “OK” to have the OK to have the violation appear in this field.

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Compliance Investigations

• In the

“Substantiated” field, select the correct description correct description

• f “Yes”, “No”, or

“Pending”, based

• n facts that you

have gathered to substantiate whether the alleged activity did

• ccur and what

stage of the investigation you are in.

Compliance Investigations

• In the

“Investigation Status” field, select “Complete” or “In Progress” to reflect the status of your investigation investigation.

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Compliance Investigations

• The “Claim

Amount” field is used to document the dollar amount

• f benefits

which are wrongfully bt i d

• btained or

disposed of.

Compliance Investigations

• By clicking on

the “Complaint” button, you will be taken back be taken back into the Complaint log to change any incorrect details logged. B li ki

• By clicking on

“Assign” you will assign this case to the family in the system.

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Compliance Investigations

• By clicking on

“Save” you will save the i f ti information logged into this screen.

• By clicking on

“Cancel” or “Close” you will y be taken back to the Household Summary Screen.

Compliance Investigations

• Now let’s take a look at what a

completed Compliance Investigations Screen looks like.

• It is important to remember to always

document each action you take in conducting an investigation.

• Details and dates are important in

determining actions and sanctions determining actions and sanctions which will be taken.

• Please do not forget to document what

you have done.

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Compliance Investigations

• Investigation Notes

have been added as steps in conducting the investigation t e est gat o have been taken.

• Notes may be

removed by clicking in front of the row to be removed and clicking on the “Remove” button Remove button, however, this is an end of day function and can only be done on the same day a row is added.

Compliance Investigations

Wh h b bl t d t i th t When you have been able to determine that an allegation is substantiated, document as “Yes” in the “Substantiated” field, select “Complete” in the “Investigation Status” field.

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Compliance Investigations

• Now let’s look at the process that you

will take in conducting an investigation. f

• The first step to take when receiving a

report of client fraud and abuse is to try to contact the client by phone or in person.

• Tell them what was alleged regarding

Tell them what was alleged regarding their WIC participation and give them a chance to explain the situation to you.

Compliance Investigations

• The key in determining whether client

fraud and abuse was committed is whether you can prove that the fraud and abuse was intentional.

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Compliance Investigations

• In this test compliance case, a neighbor

called to complain that she witnessed Mary Contrary selling infant formula.

• The clerk who answered the phone call

logged the complaint, sent the message to the LA Coordinator, also notified her by phone that a complaint was logged by phone that a complaint was logged.

Compliance Investigations

• The LA Coordinator/Complaint

Investigator contacts the client or authorized person to notify her that an authorized person to notify her that an allegation was made regarding her use

• f WIC benefits.
• Arrange to meet with the client or

discuss by phone.

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Compliance Investigations

• After interviewing the client/authorized

person, reviewing the WIC Client Agreement and re-educating the client Agreement, and re-educating the client regarding WIC Program violations and potential penalties, ask questions to determine whether the fraud and abuse was intentional.

• Explain that the client has a right to a

Fair Hearing.

Compliance Investigations

• Analyze the information to determine if

there is sufficient evidence to b t ti t th ll ti substantiate the allegation.

• If so, document appropriately on the

Compliance Investigations Screen.

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Compliance Investigations

• If it has been determined that WIC Benefits

have been obtained or disposed of improperly, the dollar value of the benefits must be calculated using the EPPIC System.

Compliance Investigations

• Enter the dollar amount of benefits used

improperly into the “Claim Amount” field

• n the Compliance Investigations”
• n the Compliance Investigations

Screen.

• In EPPIC you can search by date for

transactions which occurred during the time of the fraud and abuse. Obt i t ti d t il b li ki

• Obtain transaction details by clicking on

the “Detail” button for each transaction date.

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Compliance Investigations

• Here is an example in test of where the

transaction “Detail” button can be found in the EPPIC System in the EPPIC System.

Compliance Investigations

• Detail of purchases by date can be seen in the

“Detail” screen when a search is done. Search date has been changed to bring up the transactions during period when fraud was committed.

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Compliance Investigations

• Add all of the transactions that were

made during the time of the fraud and abuse.

• Contact the State Compliance Lead to

verify amounts.

• Example:
• 102.88 7/16/10

078 66 7/20/10

• 078.66 7/20/10
• 181.54 Total

Compliance Investigations

• This screen

shot shows a completed Compliance Investigation with the Claim Amount

• wed back
• wed back

to the Michigan WIC Program.

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Compliance Investigations

• Now you are ready to apply a sanction,

print the Compliance Letter, and also t tit ti f th t l request restitution of the monetary value

• f benefits obtained or disposed of

improperly when appropriate.

• When Restitution is required, contact

the State Compliance Lead to help the State Compliance Lead to help coordinate repayment efforts.

Compliance Investigations

• We have already demonstrated how to

calculate the restitution amount owed to the State the State.

• Note that any amount of benefits used

improperly requires repayment and should be entered into the “Claim Amount” field on the Compliance p Investigations” Screen.

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Applying Sanctions

• To apply a

Sanction, you must first make the Family

Miscellaneous

the Family active.

• Select

Sanctions from the Miscellaneous

Sanctions

Miscellaneous drop down.

Applying Sanctions

• This will take

you to the Sanctions screen.

• Click on the

“Case Number” drop down

• the correct

case number will appear in this field and should be selected.

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Applying Sanctions

• Select and

apply the appropriate

1 Y Di lifi i

pp p Sanction Action from the drop down.

• See MI-WIC

1 Year Disqualification

Policy 9.01, Exhibit B for Sanction Actions.

Applying Sanctions

• The “Sanction

Eff ti D t ” ill Effective Date” will be automatically assigned 15 days into the future to allow the client to request a Fair request a Fair Hearing.

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Applying Sanctions

• Note that sanction actions are revised in MI-

WIC Policy 9.01, Exhibit B. 30 60 and 90 da Sanction Actions ill be

• 30, 60, and 90 day Sanction Actions will be

disabled with the new release, however will remain in the system at this time.

• These have been replaced with Sanction

Actions of a Warning, 6 months, or 1 year disqualification based on the severity of the disqualification, based on the severity of the fraud and abuse.

Applying Sanctions

Enter Claim Amount in the “Due” field. Please have State Compliance Lead double check the restitution restitution amount total, as this number will also be reported to the USDA.

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Applying Sanctions

• “Letter Insert” field should be used to insert the

Violation Type as defined in Exhibit 9.01 B.

• Click “ok” to enter the Violation Type into the field

(pop up dialog box). In this case it is “Selling WIC foods for cash”.

Applying Sanctions

Repayment

• When a Compliance Letter will include a restitution

payment amount, as in this case, another sanction action of “repayment” must be added to the Sanction Screen in order for the claim amount to appear in the Compliance Letter.

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Applying Sanctions

• Also make sure

that you have documented the documented the “Claim Amount” in the Compliance Investigations Screen or it will Screen or it will not appear in the Compliance Letter.

Applying Sanctions

• After adding the

Sanction Action, click “Save” and a web dialog will pop up asking if you wish to print a Repayment Sanction letter.

• Click “Yes”.
• Letter may be

printed directly from this page or you may access it in the Print Docs screen.

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Applying Sanctions

Th C li L tt h ld b t b

• The Compliance Letter should be sent by

Certified Mail or hand delivered to the client on the same day.

• Be sure to document this action in the

“Investigation Notes” field on the Compliance Investigations screen Investigations screen.

• When appropriate, according to policy, staff

should void out future benefits as well as current.

Restitution Payments

• The Compliance Letter instructs the client to call

the WIC Coordinator to let him/her know how payment is going to be made. Payment may be made in a lump sum or with a payment plan. p p y p

• When the client contacts you regarding

repayment, report this to the State Compliance Lead who will coordinate the payments from that point on.

• Payments are made to the State of Michigan,

WIC Division, address is inserted in the C li L tt Compliance Letter.

• Restitution payments are tracked by the State

and reported to the USDA.

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Restitution Payments

• The State Compliance Lead will

complete the rest of the information in th MI WIC S t di t the MI-WIC System regarding payment amounts.

• Local Agency Coordinator will be sent a

letter when payment has been made in full and a determination will be made full and a determination will be made whether the client may be reinstated into the Program.

Unsubstantiated Allegations

• Any allegation of fraud and abuse that is

made and logged into the MI-WIC S t t b i ti t d System must be investigated.

• Next we will take a look at what actions

should be taken when an allegation is unsubstantiated.

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Unsubstantiated Allegations

• When a

Compliance Investigation is Investigation is begun, the investigation status should be reported as pending investigation investigation.

• “Investigation

Status” should be reported as “In Progress”.

Unsubstantiated Allegations

• Contact the client and obtain the facts of

what actually occurred. U i t i i th li t if th f t

• Upon interviewing the client, if the facts

do not substantiate intentional fraud and abuse, it may be determined that the complaint was unsubstantiated.

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Unsubstantiated Allegations

• In that case, select “No” in the “Substantiated” field

and select “Complete” for “Investigation Status”.

• Since there is no claim amount, that field should be

left blank.

Unsubstantiated Allegations

• A Warning Letter should be sent to the

client. M ki th f il ti t th

• Making the family active, go to the

sanctions screen.

• Select a “Warning Letter” sanction action

and insert the client violation type in the “Letter Insert” field.

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Unsubstantiated Allegations

• Print the Warning Letter and mail via

certified mail or deliver in person within 24 hours 24 hours.

• Document all attempts to contact the

client in the Compliance Investigations Screen.

• Keep all non-system documents on file

p y for 3 years and 150 days.

Client Complaint and Investigation Summary Report

• This report is run by case number by

clicking on “Reports”, “Participation”, “Client Complaint and Investigation Summary”.

• This report gives you a summary of the

actions and findings that have been actions and findings that have been found to date in any case.

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Client Complaint and Investigation Summary

Reports Participation Client Complaint and Investigation Summary

Client Complaint and Investigation Summary

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Client Complaint and Investigation Summary

• This report is a printout of the fields of the

Compliance Investigations Screen in the MI- WIC System WIC System.

• These are being monitored by the State

Compliance Lead to see what types of client fraud and abuse are occurring and to assist Local Agency Coordinators regarding the g y g g investigation process.

Client Fraud and Abuse

• Thank you for taking the time to view

this webcast. ff

• We appreciate your efforts to help

reduce WIC client fraud and abuse.

• Please call the WIC DuJour line if you

have any questions regarding client fraud and abuse 1-800-942-1636 fraud and abuse. 1 800 942 1636.