Fraud Detection & Prevention System For Participant Integrity - - PowerPoint PPT Presentation

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Presentation to: Presented by: Date:

Fraud Detection & Prevention System For Participant Integrity (FDPS)

FY2016 WIC Special Project Grant Nutrition Services Directors Meeting Chavis Paulk, MPA December 13, 2016

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Fraud Detection and Prevention System (FDPS) - Objective

• The objective of the Fraud Detection and Prevention System is to combat potential fraud and

abuse within the GAWIC Program through the use of advanced quantitative analysis and collaborative initiatives with bordering states. This project received approval and funding via the 2016 WIC Special Projects Grant administered by United States Department of Agriculture (USDA). – The amount of actual fraud detected is interconnected to the effectiveness of the effort expended and tools used on detection. Low occurrences of detected fraud could either indicate that fraud is rare or suggest that inadequate detection procedures are in place.

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GAWIC At A Glance

The Georgia WIC Program (GAWIC):

• Is the nation's fifth largest WIC Program.
• For June FY2016, GAWIC provided

benefits to approximately 250,299 participants.

• As of June FY2016, GAWIC’s cumulative

food cost totaled approximately $91.5 million.

• The participant fraud investigations for FFY

2015 represent approximately .090% of Georgia WIC participants.

29% 44% 21% 0.15% 3% 3%

Participant Demographics By Race/Ethnicity

White Black or African American Hispanic or Latino

62% 38%

Participant Demographics By Sex

Female Male

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Fraud Detection and Prevention System (FDPS) - Collaborations

• Local Agency (LA) Participation

 The Fulton County Department of Health & Wellness (Atlanta, GA)  Southwest Health District (Albany, GA)  West Central Health District (Columbus, GA)  Coastal Health District (Savannah, GA)  Northwest Health District (Rome, GA)  East Central Health District (Augusta, GA)

• Georgia Department of Public Health

 Office of The Inspector General  Office of University Relations

• Emory University

 The Rollins School Of Public Health

• Border States

 Tennessee  Alabama  Florida  South Carolina  North Carolina

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Evaluation Conceptual Approach

– Focus Groups

– Will identify and assess methods of preventing and detecting fraud that are currently in use or proposed methods that have potential use. The logic of the current and proposed controls will be evaluated by State WIC Office (SWO) and LA WIC staff who have extensive and direct experience with the fraud control. Identify and evaluate the methods of detecting participant fraud by reviewing existing tools and systems presently used by selected LA WIC Office. Examine existing or proposed tools to assess relative value/usefulness of methods. Recommend existing or new tools that are deemed to be effective best practices that maybe adopted to improve the integrity of the program. Develop a set of best practices reflecting effective strategies, approaches and tools/techniques that are currently in use or can be used for WIC fraud detection and prevention.

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FDPS Evaluation Framework

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Local Agency Participation

 East Central – Augusta (East Bordering)  Northwest – Rome (North Bordering)  Southwest – Albany (Rural)  Coastal – Savannah (Southern Bordering)  Fulton – Atlanta (Urban)  West Central – Columbus (West Bordering)

Public Health Districts

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Local Agency Participant Investigations (Case Type)

DISTRICT

NUMBER OF ALLEGATIONS

Southwest - Albany (8-2)

22

Advertising/Selling WIC Items

3

Buying Vouchers

1

Dual Participation

6

Providing Falsified Verification

1

Selling Vouchers

11

East Central - Augusta (6-0)

8

Advertising/Selling WIC Items

1

Dual Participation

6

Providing Falsified Verification

1

West Central - Columbus (7-0)

13

Counterfeit Check/Voucher

1

Dual Participation

7

Providing Falsified Verification

3

Selling Vouchers

1

Unreported Income

1

Fulton County (3-2)

83

Advertising/Selling WIC Items

9

Cash/Credit from food vendor in exhange for WIC items

1

Dual Participation

14

Household Composition

1

Providing Falsified Verification

3

Selling Vouchers

50

Unreported Income

5

Northwest - Rome (1-1)

20

Advertising/Selling WIC Items

13

Cash/Credit from food vendor in exhange for WIC items

2

Dual Participation

3

Selling Vouchers

1

Unreported Income

1

Coastal - Savannah (9-1)

274

Advertising/Selling WIC Items

6

Counterfeit Check/Voucher

1

Dual Participation

11

Household Composition

1

Selling Vouchers

254

Unreported Income

1

Grand Total

420

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Local Agency Participant Investigations (Referral Type)

DISTRICT NUMBER OF REFERRALS SOURCES Southwest - Albany (8-2) 32 Data Analysis 7 DPH OIG Investigation 7 Health Districts 3 Hotline 3 Internet/Social Media 3 Participant Project 6 USDA-OIG 3 East Central - Augusta (6-0) 15 Data Analysis 7 DPH OIG Investigation 1 Health Districts 2 Hotline 4 Internet/Social Media 1 West Central - Columbus (7-0) 18 Clinic Voucher Integrity Check 4 Data Analysis 5 DPH OIG Investigation 1 Health Districts 1 Hotline 3 Internet/Social Media 3 USDA-FNS 1 Fulton County (3-2) 123 Data Analysis 56 DPH OIG Investigation 9 Health Districts 8 Hotline 14 Internet/Social Media 4 Local Law Enforcement 1 Participant Project 3 USDA-OIG 28 Northwest - Rome (1-1) 30 Data Analysis 4 DPH OIG Investigation 5 Health Districts 3 Hotline 6 Inter Agency 1 Internal State Agency 1 Internet/Social Media 8 Local Law Enforcement 1 USDA-OIG 1 Coastal - Savannah (9-1) 280 Data Analysis 7 DPH OIG Investigation 1 Health Districts 1 Hotline 2 Internal State Agency 2 Internet/Social Media 10 USDA-OIG 257 Total 498

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Local Agency Focus Participation (Experience)

DISTRICT YEARS OF PUBLIC HEALTH EXPERIENCE YEARS OF WIC EXPERIENCE Coastal - Savannah (9-1) 60 60 Administration 18 18 Clerical 35 35 Clinical 7 7 East Central - Augusta (6-0) 56 56 Clerical 56 56 Fulton County (3-2) 69 43 Administration 5 5 Clerical 64 38 Northwest - Rome (1-1) 56 50 Administration 16 16 Clerical 18 12 Clinical 22 22 Southwest - Albany (8-2) 84 84 Administration 43 43 Clerical 39 39 Clinical 2 2 West Central - Columbus (7-0) 73 64 Administration 26 17 Clerical 47 47 Grand Total 398 357

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Albany

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Augusta

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Columbus

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Rome

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Savannah

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Fulton

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FDPS Technical Framework

Participants

Enroll

Local Clinics

Issue benefits in the form of vouchers

Vendors

Redeem benefit Redeem vouchers Payment FDPS Vendor Management System Certification System Payment Data Support Upload Data

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FDPS Technical Approach

Part 1 – Analytical Models  Rules-Based Models - Red flag certain transactions automatically.  Anomaly Models - Raise suspicion based

• n employing factors that seem

improbable.  Predictive Models - Compare redemptions against a fraud profile and raise suspicion.  Spatial Analysis - Geographical analysis which explains patterns of behavior and its spatial expression in quantitative and geometric terms  Network Link Analysis - investigating social structures through the use of networks and linkage of data

PLAN Create Datasets Define Objectives Build Model BUILD Calculate A Score Validate Model IMPLEMENT Apply Model Rank Drive Initiatives

Model Development

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Analytical Models – Network Link Analysis

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FDPS Technical Approach

Part 2 – Data Collection & Storage For Dual Participation Analysis 

Establish Data Sharing Agreements With Bordering States

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Output Analysis

NO Referable Act? No Further Action Required

1 2 3 4 5 Fraud And Detection System Output Analysis

YES WIC Legal Unit WIC Program Operations Disposition Of Referral Recorded Adverse Action Recorded Adverse Referral Submitted Office Of Inspector General YES Warrants Investigation NO No Investigation Investigation Takes Place Disposition Of Referral Recorded

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Tentative Implementation Schedule

Aug 2016

Contract & Project Plan In Place

Sept 2016

Functional Requirements Documentation

Feb 2017

Complete Development

Mar 2017

Testing

May 2017

Complete Implementation

July 2017

Go Live

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THANK YOU!