VFC Fraud and Abuse

As childhood vaccines become more expensive and immunization programs more complex, the VFC program becomes more vulnerable to fraud and abuse. It is important that grantees' VFC programs have well-defined processes for prevention, identification, investigation and resolution of suspected cases of fraud and abuse within their VFC programs.

Fraud: an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Abuse: provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program, [and/or 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.

Within Module 10 of the VFC Operations Guide[241 KB, 9 pages] you will find the following information:

• Examples of fraud and abuse
• Failure to comply with VFC requirements
• Addressing Provider Non-compliance with VFC Requirements
• Awardee Fraud and Abuse Requirements
• Using and applying the Non-compliance with VFC Provider Requirements Protocol
• Reporting of VFC Fraud and Abuse Cases for further investigation
• Preparing a referral to the Medicaid Integrity Group Field Office
• Fraud and Abuse Prevention

 

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