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Working Connections Child Care (WCCC) Manual
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Overpayments

A.  Determining Overpayments
Revised:  February 7, 2007
For question about FRAUD, please see the FRAUD chapter.

Effective May 28, 2005

WAC 170-290-0270  What is a WCCC overpayment and what can be included?

  1. A WCCC overpayment:

    1. Occurs when you or a provider receives benefits or payment from WCCC that you or they are not eligible to receive;

    2. Is written by us and expected to be paid back by you or the provider; and

    3. Is written for the month care is billed for, not the month it is paid or the month the overpayment is written.

  2. When setting up an overpayment, we reduce the WCCC overpayment by the amount of the WCCC underpayment when applicable.

  3. In areas not covered by this section, you are subject to chapter 388-410 WAC (Benefit errors).

  4. Payments made through departmental error fall under subsection (1) of this section.

  5. Absent days can be added to an overpayment, either yours or the provider's, when care is used or billed when you were not eligible for WCCC per WAC 170-290-0032 or care is billed incorrectly.

Note: This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. Absent days the provider is allowed to bill are not included in the overpayment to the consumer or to the provider unless the absent days were billed based on care the consumer used when the consumer was not eligible for the benefit. Check the provider booklet for information on how to bill absent days.

EXAMPLE

The consumer’s approved activity ends May 20th and they continue to use care without reporting the change to the department. The department discovers this June 2nd and sends a ten-day termination letter effective June 12th. The consumer stops using care on June 5th. The provider is allowed to bill 5 absent days if the child attended 1 day in June. Although this is not a benefit the consumer receives directly, the payment for the absent days is a result of the consumer using care they were not eligible for. The consumer overpayment is for all the days the consumer used and the provider appropriately billed.

  1. Unless the overpayment is for the copayment, the copayment amount is not included in the overpayment calculation because DSHS does not make this payment.

EXAMPLE

The copayment is assessed at $15.00 for July 1st, the first two months of eligibility and $200.00 for the rest of the eligibility period through December 31st. The authorization is not adjusted to increase the copay timely and the September invoice prints with the $15.00 co-payment. The worker discovers this October 15th, before deadline, and corrects the copayment amount on the authorization to $200.00 effective October 1st. There is an overpayment of $185.00 assessed to the:

  1. Provider if the consumer paid the $200.00 for September; or

  2. Consumer if they did not pay the $200.00 for September.

  1. Holiday(s) are treated as absent days if the child has left care within the month unexpectedly and a holiday occurs after their last day of attendance.

EXAMPLE

Junior leaves care on October 14th, prior to his scheduled authorization end date. After his last day of attendance, there are two state holidays. Count these as absent days because they occur after he left care. Junior’s total absent days for the month of November is 10, the provider should bill no more than 17 units.

Effective December 1, 2005

WAC 170-290-0271  When might I get an overpayment?

You get WCCC overpayments whether you are a current or past WCCC consumer, when we make payment for WCCC benefits and:

  1. You are no longer eligible or you are eligible for a smaller amount of care, such as using care for an unapproved activity or for children not in your WCCC household;

  2. You fail to report information to us that results in an error in our determination of:

    1. Your eligibility;

    2. The amount of care authorized; or

    3. The amount of your copayment.

  3. Your provider is not an eligible provider per WAC 170-290-0140;

  4. Your child is not eligible per WAC 170-290-0015 or 170-290-0020.

    5.

Note: This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. The AW establishes the overpayment to the consumer for care used and billed when the consumer:

    • Was ineligible for part or all of the child care benefits, or

    • Used an unapproved or ineligible in-home/relative provider.

Example 1

A consumer is working and is approved for WCCC. Their employment ends May 15th  and they do not report this to the department. On August 4th the department discovers the consumer is not in an approved activity, and a ten-day termination notice is sent effective August 14th. All care used and billed from May 16th through August 14th is an overpayment to the consumer.

Example 2

A consumer is using a licensed/certified center. The child turns 13 and she continues to use the provider because the provider has a waiver. The consumer has not received approval for Special Needs Payment. All care billed from the child’s 13th birthday is an overpayment to the consumer.

  1. Consumers (TANF or non-TANF) approved for activities (such as work, job search, community jobs, IRP activities, or school) may use their child care (licensed or in-home/relative care) for family support activities (such as medical appointments, illness or injury) as long as their approved activity is still active (for employment, they would need to continue to receive income). Please see WORKER RESPONSIBILITIES FOR MORE INFORMATION.

EXAMPLE 1

Beth is approved for WCCC for WorkFirst job search. She is authorized for 22 full day units. Her scheduled attendance days are Monday-Friday. She reports sick to job club Thursday and Friday and uses the child care. As long as Beth remains eligible for job search she does not receive an overpayment for using child care on a scheduled job search day that she did not participate due to an illness.

EXAMPLE 2

Kate is working and is approved for 22 full-day units. Her scheduled work week is Monday-Thursday. She is unable to work due to an injury. She reports sick to work and uses the child care Wednesday-Friday. Beth does not receive an overpayment for using child care for a scheduled work day that she did not work due to the injury, but would receive an overpayment for using care on a non-work day. In this case, she would receive an overpayment for Friday.

EXAMPLE 3

Janice is working and is approved for 22 full-day units. Her scheduled work week is Monday-Friday. She has two children in child care. She is attending counseling for herself and one child. She leaves the other child in child care while attending the counseling sessions. Beth does not receive an overpayment for using child care for a scheduled work day that she did not work due to a counseling appointment.

EXAMPLE 4

Barbi was employed until she became ill and was released from work. After she is released from employment, she continues to uses child care due to her illness. Barbi is not eligible for child care for her illness once her employer terminated her. Any care used after her employment ended would be an overpayment.

WORKER RESPONSIBILITIES

You do not need to verify every day a consumer misses work due to medical appointments (including counseling), illness or injury. As long as the consumer is still employed they may use care for sick days and medical appointments (including counseling appointments). The consumer’s verbal statement of why they missed work and used child care can be accepted. You may need to verify the consumer’s statement:

  • To be sure the consumer is still employed if the absence from work because extensive; or

  • If someone reports the consumer was using the child care for something other than a family support activity as described under the clarifying information above.

Effective December 1, 2005

WAC 170-290-0273 When would my licensed or certified provider or DSHS contracted Seasonal Day Camp get an overpayment?

  1. We establish WCCC overpayments for your licensed or certified child care provider and DSHS contracted seasonal day camps, when your provider:

    1. Billed and received payment for WCCC services not provided;

    2. Does not have attendance records that comply with licensing requirements (refer to WAC 170-295-7030, 170-296-0520, and 170-151-460 for attendance record requirements). Only attendance records meeting WAC requirements will be accepted for attendance verification;
      (editor's note: WAC number's were changed in the manual WAC to match the changes in licensing WAC)

    3. Billed and received payment for more than they are eligible to bill;

    4. Billed and received payment and the provider is not eligible based on WAC 170-290-0125; or

    5. Is caring for a child outside their licensed allowable age range without a waiver.

  2. The WCCC program staff may request documentation from your provider when preparing to establish an overpayment. Your provider has fourteen consecutive calendar days to supply any requested documentation.

Note: This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

  1. Provider/vendor overpayments include:

    1. Payment to the licensed/certified provider they are not eligible to bill for per the provider booklet (DSHS 22-877(x));

    2. Payment to the licensed/certified provider at a rate higher than the provider's customary rate.

Example 1

A licensed/certified family home provider cares for a child over the age of 12 and there is no licensing waiver. Establish the overpayment to the provider for all days billed from the child's 12th birthday.

Example 2

A consumer's last day of attendance was July 31st. The provider bills 5 absent days on the August invoice. Establish the overpayment to the provider, as the provider was ineligible to bill for any days in August.

Example 3

A child starts care on May 15th. There are only 12 possible billing days left in the month in a Monday-Friday activity schedule. On the invoice, the provider bills for 17 days. Following the provider booklet (DSHS 22-877(x)), the provider over billed by 5 days. Establish an overpayment to the provider for 5 units.

Effective December 1, 2005

WAC 170-290-0274 When would my in home/relative provider get an overpayment?

  1. We establish WCCC overpayments for your in home/relative provider when your provider:

    1. Billed and received payment for WCCC services not provided;

    2. Does not have attendance records that comply with attendance records based on WAC 170-290-0138. Only attendance records meeting WAC requirements will be accepted for attendance verification;

    3. Billed and received payment for more than they are eligible to bill;

  2. The WCCC program staff may request documentation from your provider when preparing to establish an overpayment. Your provider has fourteen consecutive calendar days to supply any requested documentation.

Note: This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

In-home/relative providers will be responsible for overpayments resulting from billing and receiving payment they are not eligible for.  This can include billing and receiving payment for more:

  • Hours than they provided; or

  • Than 6 children for the same time periods.

Monitoring child care payments and authorizations

  1. The department is responsible to review monitoring reports and to evaluate information as needed for possible overpayment action.

  2. The following staff monitor case activities:

  1. The Department of Early Learning (DEL);

  2. The Social Service Payment Systems staff (SSPS);

  3. The Administrative Services Division, Operations Review/Consultation (by request only);

  4. The Office of the State Auditor;

  5. Division of Employment Assistance Program;

  6. CSO/CSC staff; and

  7. The Payment Review Program (PRP).
     

  1. Monitoring activities may include reviews of case records in WCAP, documents in DMS, SSPS reports, E-JAS on-line case information, ACES, SEMS, on-site visits to a child care facility or home and, telephone and/or written communication with DSHS staff, consumers, providers and licensors.

worker responsibilities

Discovering overpayments

Use the following methods to discover possible overpayments:

  1. Read SSPS reports including:

    1. SSPS 031 (Provider Listing by Paid Service Report);

    2. SSPS 032 (Worker Service Report);

    3. 40N40 (Client Payment Detail Listing Report) and the;

    4. 40N51 (Child Care Payment Alert).

    These reports are available on the SSPS COLD Report System.

  2. Ask the following questions when reviewing for possible overpayments:

    1. Is the licensed/certified provider consistently claiming the maximum number of units authorized, (i.e., 22 full-days, 22 to 30 half days per month)?

    2. Is the authorization for in-home/relative care consistently billed for the maximum authorized units per month?

    3. Is the in-home/relative provider claiming for WCCC payment for more than 6 children for the same time period (overlapping days and hours)?

    4. Is the in-home/relative provider billing for non-school/holiday hours (continguency hours) they are not eligible for. Such as, the child is not school aged or they did not provide the care?

    5. Does the authorized payment exceed the DSHS rate for the child's age or geographic area?

    6. Is there a service code that does not match the provider type (i.e. the 2950 for full-time center care is authorized for a family home)?

    7. Is a child age 13 years or older being authorized for care? (Only children age 13 and older who have special needs or who are under court supervision can be authorized for child care). If the provider is licensed/certified, they must have a waiver. Or is there a 12 year old in a licensed/certified family home authorized for care without a waiver?

    8. Are there duplicate authorizations and payments for a child?

EXAMPLE

A child's name is listed on the SSPS Payment Alert Report SPS40N51 more than once for the same dates or overlapping dates. Explore whether there is an error in the authorization or if there has been an inappropriate duplicate billing. If so, an overpayment is established to the payee (consumer or provider). If the authorizations are ongoing and correct, then the duplicate service needs to be closed and re-opened with a “9” code.

  1. Review information in the case record to determine:

    1. If the need for child care is clearly supported in the case file including household composition and approvable activities;

    2. Total hours of care needed;

    3. If the income was determined correctly; and

    4. The copayment was applied correctly.

  2. Review the SSPS authorization documents to note if the authorization is accurate, including:

    1. Service code(s);

    2. Reason codes(s);

    3. Children's ages;

    4. Authorization periods;

    5. Total hours of care approved; and

    6. Rate of payment, including correct copayment authorized.

  3. When reviewing a case, check the SSPS S02 screen, and if necessary for in-home/relative care the S01 screen (for school holiday hours billed), for payment history going back 13 months. Use the SSPS COLD system for care older than 13 months.

    If the case is active, compare the billing with the consumer's approved activity and either increase or decrease the authorization as appropriate.

  4. If the reviewer is from PRP, they will process the overpayment. Overpayments completed by PRP will be electronically documented in WCAP case notes and overpayment screens. OFR sends the consumer/provider an overpayment notice directing them to call a toll free number if they have questions. Field staff are not required to answer questions regarding PRP overpayments. If the field staff is called with a question regarding a PRP overpayment, refer the caller to the toll free number from their form. Hearing requests generated from PRP overpayments will go through OFR. PRP will represent the department at the Hearing. DSHS staff will continue assisting consumers in completing hearing requests as needed.

Example

Verifying overpayments

To verify an overpayment, do one or more of the following:

  1. Gather, analyze and verify all the necessary information;

  2. Contact the consumer and/or provider to request an explanation of what may have caused the overpayment;

  3. Verify the consumer's scheduled hours of participation in an approved educational, training, WorkFirst or employment activity.

  4. Request the consumer verify child care attendance when a dispute arises with the provider's reported attendance.

  5. Review the licensed/certified provider's attendance records (as a last resort) if discrepancies, omissions, or inconsistencies are noted while reviewing the case. Licensed/certified providers must keep daily attendance records per WAC 170-295-7030 for centers and WAC 170-296-0520 for homes and WAC 170-151-460 for school age facilities. If the provider cannot produce attendance records in accordance with the WAC's, call the CPS intake line and make a report. This information is passed on to the DEL Licensor.

    The following can be accepted as a consumer signature for WCCC:

    • A signature matching other signatures from the consumer (For CSO/CSC staff the ECR may have other documents with examples of the consumer's signature);

    • Last name, first name;

    • First initial and last name;

    • Initials;

    • Illegible signatures if that is how the consumer normally signs documents.

    Use as much information on the attendance form as possible to determine if an overpayment is needed. If the signatures are incomplete, such as the consumer signed in but not out, do not process an overpayment. The provider is owed payment if care was provided. Refer these to the CPS intake line as a licensing issue.

    Some providers use electronic attendance keeping. Electronic signatures do not meet licensing WAC. Licensed/Certified providers must use a hand written attendance system to meet WAC requirements.

    Tribes who want subsidy payments must follow the licensing WAC for attendance keeping requirements.

EXAMPLE

Happy Tots is requested to turn in their attendance records for a possible overpayment for child Barney. On two days Barney's mom signed him in, but forgot to sign him out. It is clear Barney attended child care that day. You may accept Barney's mom's sign in as verification he did attend care. Since the provider is not following their WAC requirements, make a report to CPS regarding the licensing issue.

  1. Review in-home/relative care attendance records. The in-home/relative care attendance keeping requirement is noted WAC 170-290-0138 and is included on the in-home/relative award letter sent from WCAP (letter 07-075) and on the DEL14-417(X) WCCC Application, Part 2 that is required to be signed by the consumer and the in-home/relative provider and kept in the consumer's Electronic Case Record (ECR).

  2. Ask licensors if a provider has a waiver for children who are not covered by the provider's license. Providers incur an overpayment for dates of service not listed on the waiver. This includes the time period prior to the waiver approval date and the last date the provider was allowed to bill for the child.

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