SO: 1 Reporting and Investigating Fraud and Abuse (New)

Effective Date: 10/07 Downloads: PDF Version    Revised Date: 02/17
   

Policy

The Nevada WIC program will investigate all allegations of fraud/abuse being committed by WIC participants, WIC local agency employees, and WIC authorized grocers.

 

Procedure

All

 

Reporting

Complaints can be filed by either:

  • Calling the Nevada toll-free number 1-800-863-8942
  • Writing to:

400 W King Street, Ste 300

Carson City, NV 89703

Nevada State WIC Program

Examples of program abuse include but are not limited to:

  • Making false or misleading statements or misrepresenting, concealing, or withholding facts to obtain Program benefits.
  • Exchanging food instruments or supplemental foods purchased with WIC food instruments for cash, credit, non-food items, or unauthorized food items.
  • Exchanging food instruments for more than the specified amount of supplemental foods listed on the food instrument.
  • Theft of food instruments.
  • Physically harming, or threatening to harm WIC clinic or food vendor staff.
  • Redeeming more than the number of food instruments for which the participant is eligible.
  • Altering the food instrument.
  • Redeeming food instruments at an unauthorized food vendor.
  • Redeeming food instruments before the issue date or more than 30 days after the issue date.
  • Allowing WIC foods to be used by or giving away WIC foods for other than the participants use.
  • Sale of WIC foods, WIC food instruments or exchange with other individuals or entities.

Dual Participation means either:

  • Simultaneous participation by the same person(s) in more than one WIC  local agency or more than one WIC clinic site within a local agency                       

Reporting and Documentation of Program Abuse

Once program abuse by a participant, alternate, proxy, parent, guardian, caretaker, or representative of the participant is suspected or a complaint has been received, the local agency is required to begin an investigation and is instructed to:

  1. Document the incident in the participants file (i.e. date, time, brief explanation of facts, witnesses’ statement’s etc.) to the fullest extent possible.
  2. Obtain & document participant’s point of view. If the participant cannot be contacted by phone, a letter will be sent instructing the participant to contact the clinic. Document all attempts to contact the participant if they are unreachable. When the participant contacts the clinic local agency staff will clarify the issue with the participant and inform them that an investigation is in process.
  3. Local agency staff must complete the investigation within 120 days of any incident.
  4. If local agency staff determines that there are not sufficient facts for a finding that the participant, proxy, parent, guardian, caretaker, or representative of the participant, intentionally committed a program violation, staff will document and provide a Warning (refer to explanation below) using the “Notice of Ineligibility, Placement on Waiting List or Disqualification” form. A copy of this form will be retained in the participants file.
  5. If the local agency has determined that an intentional violation has occurred, they are to forward all supporting information to the State Office within 2 working days of the completion of the investigation. This includes but is not limited to:
  •  Family number
  •  Other family members on Program
  •  Length of time on Program
  •  Misrepresented information
  •  Copies of documented investigation including statement of witnesses, etc.
  •  Any information pertinent to case

6.  The State Office will apply sanctions if the intentional violation is confirmed and report back to the local agency.

Disqualification Procedures for Dual ParticipationEach month local agencies receive a copy of the Dual Participation report. If it is discovered that a participant had dual participated the local agency will:

  1. Complete the Dual Participation Report within 30 days and return to the State Office(refer to RR:3)
  2. Follow the procedures listed above for documentation of the investigation.

Dual Participation within the Nevada WIC Program:

  • Ask the eligible participant to choose one clinic site from which to continue to receive benefits, regardless of whether or not the dual participation was intentional.
  • The local agency will inform the second clinic site of the participant’s decision.
  • The local agency that the participant does not choose to participate at will immediately terminate the participant without 15 days notice and without benefits.
  • The local agency the participant chooses to participate will determine if the participant was informed of and understood that dual participation is a program violation.
  • The local agency will then take corrective action depending on the outcome of the investigation.

Unintentional Dual Participation: Issue a Warning and place in their file. A copy will also be placed in the “Participant-Vendor Complaint Log” at each clinic.

Program Violation: Forward all supporting documentation to the State Office within 2 working days of the completion of the investigation.

    3.  The State Office will apply sanctions if the violation is confirmed and report back to the local agency. A copy of all sanctions will also be placed in the “Participant-Vendor Complaint Log” at each clinic.

Examples of Possible Sanctions for Participant Abuse

Warning (Local Agency may administer)

A warning will be issued to a participant, alternate, proxy, parent, guardian, caretaker, or representative of the participant if there is not sufficient evidence for a reasonable person to conclude that the participant committed an act with the intent to violate program rules or for participants that fail to properly comprehend the training of food instruments and unknowingly violates cashing procedures.

Participants who are accused of violations but through investigation cannot be verified should be informed of the close of the investigation and given a written warning that if a violation was to occur again, the possibility of 1 year disqualification and repayment of benefits.

All participants who are found to have committed a food instrument redemption violation must receive and have documented in their file additional F.I. training.

Disqualification (State Office to administer)

Participants, alternate, proxy, parent, guardian, caretaker, or representative of the participant found to have committed an intentional program violation may be subject to:

  • 1 month disqualification if the violation (except dual participation) is a first violation and results in a claim of less than $100.
  • 1 year disqualification if the violation resulted from dual participation or a second violation (any amount) or a first violation resulting in a claim of a $100 or more.
  • Repayment of benefits from any participant violation regardless of the amount of claim.

Intention

To qualify for a one year suspension, the Participant violation must be an “intentional act of noncompliance committed by the participant.” There must be a preponderance of evidence to show intent before a one year suspension may be imposed.

Among the items that help show intent on the part of the participant includes:

  • previous instances of dual participation
  • making false or misleading statements or misrepresenting, concealing or withholding information about themselves or their family to obtain Program benefits
  • previous warnings on dual participation

If there is any question as to whether intent has been established, the State WIC Office will be consulted.

A warning will be given to a participant where an investigation of an alleged violation shows that the participant committed an act described above, but there is not sufficient evidence for a reasonable person to conclude that the participant committed the act with intent to violate program rules.

Proxies

The State has the option for participants under the age of 18, infants and children who face disqualification due to their own actions or the actions of their sponsor to approve proxies in lieu of disqualification on a case by case basis. To be approved the proposed alternate must be a responsible adult(other than the individual who committed the program violation) who is knowledgeable of the child’s eating habits and health status, capable of bring the child to required WIC appointment, capable of redeeming food instruments at the grocery store, and willing to comply with program regulations. Local agencies who feel participants qualify for this exception (violator no longer living with family, social worker involved, etc) should include this information within their documentation.