Fraud Detection & Prevention System For Participant Integrity (FDPS) FY2016 WIC Special Project Grant Presentation to: Nutrition Services Directors Meeting Presented by: Chavis Paulk, MPA Date: December 13, 2016
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.
GAWIC At A Glance Participant Demographics By Race/Ethnicity The Georgia WIC Program (GAWIC): 3% 3% 0.15% White 29% 21% • Black or African Is the nation's fifth largest WIC Program. American 44% Hispanic or Latino • For June FY2016, GAWIC provided benefits to approximately 250,299 participants. Participant Demographics By Sex • As of June FY2016, GAWIC’s cumulative food cost totaled approximately $91.5 38% million. Female 62% Male • The participant fraud investigations for FFY 2015 represent approximately .090% of Georgia WIC participants.
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
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.
FDPS Evaluation Framework
Local Agency Participation East Central – Augusta (East Bordering) Northwest – Rome (North Bordering) Public Health Districts Southwest – Albany (Rural) Coastal – Savannah (Southern Bordering) Fulton – Atlanta (Urban) West Central – Columbus (West Bordering)
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
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
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
Albany
Augusta
Columbus
Rome
Savannah
Fulton
FDPS Technical Framework Enroll Participants Local Clinics Issue benefits in the form of vouchers Redeem Upload Support benefit Data Redeem vouchers Vendors Payment FDPS Certification Vendor Payment System Management Data System
FDPS Technical Approach Part 1 – Analytical Models Model Development Rules-Based Models - Red flag certain transactions automatically. PLAN BUILD IMPLEMENT Anomaly Models - Raise suspicion based on employing factors that seem improbable. Build Model Apply Model Define Objectives Predictive Models - Compare redemptions against a fraud profile and raise suspicion. Spatial Analysis - Geographical analysis Create Calculate Rank Datasets A Score which explains patterns of behavior and its spatial expression in quantitative and geometric terms Validate Drive Network Link Analysis - investigating social Model Initiatives structures through the use of networks and linkage of data
Analytical Models – Network Link Analysis
FDPS Technical Approach Part 2 – Data Collection & Storage For Dual Participation Analysis Establish Data Sharing Agreements With Bordering States
Output Analysis No Further Referable NO Action Act? 5 Required 4 3 2 1 Fraud And Detection System Output Analysis YES Disposition Of Disposition Of Adverse Action Referral Recorded Referral Recorded Recorded Adverse Referral Submitted WIC Legal Unit Office Of Inspector General WIC Program Operations Warrants No Investigation YES NO Investigation Investigation Takes Place
Tentative Implementation Schedule July 2017 Feb 2017 Go Live May 2017 Complete Sept 2016 Development Complete Implementation Functional Mar 2017 Aug 2016 Requirements Documentation Contract & Testing Project Plan In Place
THANK YOU!
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