Fraud and Abuse Webinette National Resource Center for - - PowerPoint PPT Presentation

Fraud and Abuse Webinette

National Resource Center for Participant-Directed Services Presented by Casey Sanders Assistant Director of Training

Definitions

 Fraud: the intent to deceive  Abuse: an act of aggression by one person

intended to inflict harm on another person

 Neglect: failing to provide services that are

essential to the participant’s wellbeing

 Exploitation: taking advantage of the participant,

worker, or system by misusing finances, trust, or resources

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Common Myths

 MYTH: Participants do not have the ability to

direct their own services, perform the responsibilities of an employer, or follow program rules and obligations

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Common Myths

 MYTH: Participants are vulnerable and will

categorically be taken advantage of

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Common Myths

 MYTH: Workers with traditional, formal training

do a better job than workers trained by the participants

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Common Myths

 MYTH: Family members will not do quality work

that a traditional agency worker does

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There has been no evidence that participant direction leads to more fraud and abuse than the traditional system

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Cash & Counseling Evaluation Results

 Built-in mechanisms are effective in preventing fraud

and abuse

Representative Counselor FMS

C&C participants were less to report problems with their caregivers, such as neglecting them, being disrespectful, and taking things without asking.

Directly hired workers in Cash & Counseling reported high levels of job satisfaction.

Many Western European countries have also implemented participant direction.

Real Examples of Fraud and Abuse

 When a participant dies  Falsified timesheets  Worker has access to personal finances

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Identifying, Preventing and Managing Fraud and Abuse

 Clearly identify participant roles and responsibilities  Provide information and training  Ensure effective supports are available  Conduct monitoring activities  Establish effective communication paths

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Clearly Identify Participant Roles and Responsibilities

 Enrollment

 Program operations  Available support system and resources  Reporting and documentation requirements  Permissible and non-permissible goods and services  How to file for a hearing or appeal  Define fraud and abuse  Consequences of failing to comply with program

standards and requirements

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Clearly Identify Participant Roles and Responsibilities (continued)

 Presentation

 Providing examples  Roles and responsibilities discussed during each visit

and written materials left in the home for review at a later time

 Participants encouraged to ask clarifying questions  Create a checklist  Participant Bill of Rights

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Provide Information and Training

 How to successfully recruit, interview, and hire

workers

 How to be an effective employer and supervisor  Worker training  Completing paperwork and timesheets  States laws about fraud and abuse and mandatory

reporting requirements

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Ensure Effective Supports are Available

Participant- Directed Counselor FMS

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Effective Supports: Counselors

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Counselor

Provides support and guidance Offers explanation and clarification Links to resources

Effective Supports: Counselors

 Counselors are not responsible for participant’s

mistakes

 Counselors are responsible for identifying and

correcting mistakes

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Effective Supports: Counselor Recommendations

 Follow your program’s risk mitigation policy  Document all interactions and observations  Develop an adequate plan to provide services and

supports

 Increase monitoring efforts when there is an

indication of high risk

 After identifying fraud and abuse

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Effective Supports: FMS

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FMS

Assists with managing resources Purchases goods and services Documents and tracks expenditures Processes payroll checks Reports and withholds payroll taxes

Effective Supports: FMS

 Critical role in detecting abuse, neglect, and

exploitation

 Responsible for making sure timesheets and purchases

comply with what’s listed in the budget

 Identify inconsistencies or outliers

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Conduct Monitoring Activities

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Responsibility

Traditional Agency

Health & Wellbeing

Participant

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Conduct Monitoring Activities

Higher potential for fraud and abuse Lower potential for fraud and abuse

Establish Effective Communication Paths

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Case Manager Counselor FMS Other Service Providers Participant

Establish Effective Communication Paths: Recommendations

 Follow- up immediately when there is an indication

• f fraud and abuse

 Goal is to quickly identify the issue so that it can be

corrected before it turns into a serious problem

 Need to know the appropriate reporting chains

within your state

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There are no indications that program misuse is greater with participant direction than other service delivery methods.

Advancing choice and control for people living with disabilities

Please send your questions and comments to: info@participantdirection.org