Whistleblower Awards Available for Reporting Fraud Involving the Vaccines for Children Program
Vaccines For Children (VFC) is a federally funded program that provides vaccines to kids at no cost. Between 1986 and 2014, the real cost to immunize a child skyrocketed from $100 to $2192. Unless you have health insurance, that is too much for many families.
The VFC program insures that kids can get their shots even if the parents don’t have the ability to pay.
As currently structured, the Centers for Disease Control and Prevention (CDC) buys the drugs at a steep discount. They are then distributed to the states who in turn distribute them at no charge to participating doctors and public health clinics.
Kids are eligible for free shots if they meet the following eligibility criteria:
- Medicaid-eligible
- Uninsured
- Underinsured
- American Indian or Alaska Native
Children are eligible until their 19th birthday.
Kids that are underinsured can only get their free shots at federally qualified or rural health clinic.
Between 1989 and 1991, a measles outbreak swept the country. Tens of thousands of kids were sick and hundreds died. These deaths were all preventable since a measles vaccine was already available. Unfortunately, many families couldn’t afford the vaccine and state health assistance programs varied widely.
Congress passed legislation to form the Vaccines for Children Program in 1993. Today the program covers 16 diseases including measles.
For kids under 7 years of age, the program covers vaccines for:
- Chickenpox (Varicella)
- Diphtheria
- Flu (Influenza)
- Hepatitis A
- Hepatitis B
- Hib
- Measles
- Mumps
- Polio
- Pneumococcal
- Rotavirus
- Rubella
- Tetanus
- Whooping Cough (Pertussis)
For older kids and young adults, the program covers:
- Flu (Influenza)
- Tetanus
- Whooping Cough
- Diphtheria
- HPV (Human Papillomavirus)
- Meningococcal
Vaccines for Children Program and Medicaid Fraud
The cost of the program isn’t cheap but the CDC says it prevents millions of illnesses and saves hundreds of thousands of lives. Kids’ lives.
By the numbers, the government says that for kids born between 1994 (when the program began) and 2016, VFC will prevent 381,000,000 illnesses and avoid 855,000 deaths. The societal cost savings is estimated to be $1,650,000,000,000.00. That is $1.65 trillion!
With any large government program there is unfortunately fraud. And with VFC, that fraud often involves doctors.
Typical Vaccines for Children Program fraud involves one of more of the following:
- Providing VFC vaccine to non-VFC-eligible children. (That allows doctors to “double dip.”)
- Selling or otherwise misdirecting VFC vaccine.
- Billing a patient or third party for VFC vaccine.
- Charging more than the established maximum federally approved VFC administration fee.
- Not providing VFC vaccine to VFC-eligible children because of inability to pay for the vaccine administration fee.
- Failing to screen patients for VFC eligibility.
- Failing to maintain VFC records and comply with other requirements of the VFC Program.
- Failing to fully account for VFC vaccine.
- Failing to properly store and handle VFC vaccine.
- Waste of vaccines
A review conducted in 2007 found widespread Vaccine for Children fraud.
According to a report published by the National Institute of Health, “[more than 65% of grantees] did not have written procedures for investigating and reconciling discrepancies between estimated vaccine needs and actual vaccine-use data… Ninety percent of grantees did not have procedures to check providers for fraud and abuse sanctions, and 52% did not have written procedures to address complaints of vaccine fraud and abuse.”
In typical Medicaid programs, the states contribute a sizeable portion of the monies to run the program. VFC is funded by Congress but administered by the states (as well as a few select cities). That reduces the financial incentives for the state to police the program.
Perhaps more importantly, the states rely on participating doctors and clinics to actually provide the vaccines further reducing oversight.
The CDC admits that ramping up audits might actually hurt the program. According to the government, legitimate doctors that participate in the program “often absorb a loss when administering vaccines to children enrolled in the Medicaid program because reimbursements for vaccine administration fall below actual expenses incurred for patient visits.” They concede that too much oversight will result in honest doctors refusing to participate because of the compliance costs.
So what is the solution?
Whistleblowers! Concerned healthcare workers that are employed by these clinics and physicians’ offices are the best line of defense against fraud and abuse.
Under the federal False Claims Act and 29 state laws, Medicaid related fraud can be prosecuted in the name of the government by private citizens. The healthcare workers filing these claims on behalf of the government can keep between 15% and 30% of whatever is collected from the wrongdoers.
With high fines and triple damages, the government can really punish those that cheat the program and taxpayers while insuring that compliance costs are minimal for the doctors who choose to take less simply because they want to help disadvantaged kids.
The last government compliance survey we can find is quite old, 2002. In that survey, the government found that 28% of the state and city grantees reported abuse complaints. Now that the cost of these vaccines has more than doubled, we suspect the number of abuse incidents has grown even larger.
It’s hard to determine the accuracy of the 2002 complaint statistics since 55 of the 61 grantees (50 states plus a few select cities and territories) admitted they had no mechanism to check for past or present sanctions!
We aren’t overly critical of the lack of oversight. In complete candor, the CDC admits that putting too much of an emphasis on enforcement will force out the participating doctors who are already losing money. The goal of the program is to get as many kids as possible immunized and that means finding doctors willing to lose money.
Obviously we salute the many honest doctors who lose money yet still help needy kids. They are heroes. We are concerned about the small minority of doctors and clinics who think the program is a license to steal from either taxpayers or low income families. Chosing to participate in a program where you might lose money doesn’t give you license to steal from the very people the program is designed to help. With your help we can target those who need to be punished.
Remember, whistleblowers who file a complaint under the False Claims Act are eligible for large cash awards and are protected from illegal whistleblower retaliation.
Ready to learn more? Visit our Medicaid / Medicare fraud whistleblower page. Ready to see if you qualify for a reward? Contact us online, by email *protected email* or by phone at 202-800-9791. All inquiries are confidential and without obligation.
The post Vaccines for Children Program Fraud appeared first on Mahany Law.