What is Fraud? Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable federal or state law.
What is Abuse? Abuse refers to provider practices that are inconsistent with sound fiscal, business, or medical practices and result in:
- an unnecessary cost to the Medicaid program,
- including actions that result in an unnecessary cost to the immunization program, a health insurance company, or a patient;
- or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care
- It also includes recipient practices that result in unnecessary cost to the Medicaid program.
Examples of Fraud and Abuse
Fraud or abuse can occur in many ways, and some types of fraud and abuse are easier for the VFC/WyVIP Program to prevent or detect than others, depending on how the VFC/WyVIP Program is implemented. The VFC/WyVIP Program should try to differentiate between intentional fraud and abuse and unintentional abuse or error due to excusable lack of knowledge. Some examples of potential fraud and abuse that staff might encounter are:
- Providing VFC/WyVIP vaccine to non- VFC/WyVIP -eligible children.
- Selling or otherwise misdirecting publicly supplied vaccine.
- Billing a patient or third party for publicly-funded vaccine.
- Charging more than the established maximum regional charge for administration of a publicly-funded vaccine to a federally or state vaccine-eligible child.
- Denying VFC/WyVIP eligible children publicly-funded vaccine because of parents' inability to pay for the administration fee.
- Failing to implement provider enrollment requirements of the VFC/WyVIP Program.
- Failing to screen for and document eligibility status at every visit.
- Failing to maintain VFC/WyVIP records and comply with other requirements of the VFC/WyVIP Program.
- Failing to fully account for publicly-funded vaccine.
- Failing to properly store and handle VFC/WyVIP vaccine.
Reporting Suspected Fraud and Abuse
Any individual wishing to make a referral for a Fraud and Abuse investigation may do so by calling the Immunization Unit at 307-777-2413 or by completing and submitting the Fraud and Abuse Referral Form.
Jude Alden, MBA, CPM
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Fraud and Abuse