Medicaid Fraud and the Vaccines for Children Program

Since 1994, the federally funded Vaccines For Children program (VFC) has insured that millions of kids from needy families get the lifesaving vaccines they need. The Centers for Disease Control and Prevention says that for kids born between 1994 and 2014, the program will prevent 381,000,000 illnesses and avoid 855,000 deaths.

Medicaid Fraud and the Vaccines for Children Program

VFC does this by purchasing vaccines in bulk using tax dollars and then distributing them to all 50 states and selected cities. These local government agencies then distribute them free of charge to participating doctors and public health clinics.

Kids are eligible for free shots if they are Medicaid eligible, have no insurance, are underinsured or members of recognized tribes or Native Alaskan groups. Free vaccines are a big deal for families without insurance. In 2014, the cost to immunize a child was $2192. For many struggling families that is just too much.

Children and young adults are eligible for free shots from birth until their 19th birthday.

The program began after a horrible measles outbreak struck the United States between 1989 and 1991. Hundreds of children died simply because they never had access to readily available vaccines. While some states offered measles shots, others did not.

Congress stepped in and created the Vaccines for Children program in 1993. Today that program provides vaccinations against

  • Chickenpox (Varicella)
  • Diphtheria
  • Flu (Influenza)
  • Hepatitis A
  • Hepatitis B
  • Hib
  • Measles
  • Mumps
  • Polio
  • Pneumococcal
  • Rotavirus
  • Rubella
  • Tetanus
  • Whooping Cough (Pertussis)
  • HPV (Human Papillomavirus)
  • Meningococcal

Vaccines for Children Program and Medicaid Fraud

The program costs taxpayers over $1 billion per year but the CDC says it prevents millions of illnesses and saves hundreds of thousands of kids’ lives. As with any large government healthcare program, however, there is fraud.

Typical Vaccines for Children Program fraud involves one of more of the following schemes:

  • Providing VFC vaccine to non-VFC-eligible children. (Doctors will use the free vaccine on kids not eligible and charge kids with insurance normal rates thereby increasing their profits.)
  • 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. (Doctors can’t charge for the vaccine but they can charge the standard Medicaid rate to administer the shots.)
  • 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 properly store and handle VFC vaccine.
  • Waste of vaccines

Periodic reviews of the program have always found widespread 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 most Medicaid programs, the states contribute a sizeable portion of the monies to run the program. The states therefore have the financial incentive to ferret of fraud. Because the Vaccines for Children program is funded by Congress, however, the people administering the program have no financial stake and have fewer incentives to insure there is no fraud and abuse.

It may surprise you to know that according to the CDC, increased oversight may not be the correct solution. There is no profit margin in the plan for doctors. According to the CDC, participating doctors “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.”

Too much oversight, compliance measures and audits could result in honest doctors losing so much money that they simply opt out. And that would hurt the families that rely on the program.

But there is a solution, whistleblowers!

Healthcare workers that are employed by these clinics are the government’s best eyes and ears. They know when fraud is occurring and are uniquely positioned to protect both taxpayers and patients.

Under the federal False Claims Act, Medicaid related healthcare 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. Strong whistleblower employment protection provisions also protect workers that suffer illegal workplace retaliation.

Because these cases are investigated in secret, employees also have plenty of time to secure new employment before their identity becomes known.

The False Claims Act makes doctors and clinics that defraud the vaccine program liable for big fines and triple damages. That means the rewards can be quite large.

So how bad is the fraud problem? It’s quite bad. While most doctors are performing a wonderful service to the community, 28% of the states and cities administering the program reported fraud. That number is misleading, however, 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 need your help to find the small percentage of participants who steal from the program. Their actions hurt taxpayers, the program and the kids served by the program.

There is no place in our healthcare system for greed. With your help we can put an end to Medicaid fraud.

You can report fraud anonymously to any of the fifty states’ Medicaid Fraud Control Units. Remember, however, that reporting to the states directly doesn’t get you an award. The only way to collect an award is by filing a False Claims Act claim in federal court. We can help you do that.

Need more of a reason? Because the False Claims Act imposes strict time limits on the government to investigate, whistleblowers who file a False Claims Act cases have a far greater chance of having their complaint investigated over those making an anonymous tip.

If you see something wrong, say something. Medicaid fraud hurts taxpayers, hurts our economy, harms patients and is just plain wrong.

If you know of a healthcare provider that is cheating the Vaccines for Children program, call us. We can assist you in putting an end to the fraud and help you receive a large cash reward for your trouble. Not interested in an award, we can help you get your information to the correct state Medicaid Fraud Control Unit. Connect with us 888.742.7248 or ONLINE.

*If you are a parent and have questions about the program itself, visit the CDC Vaccine for Children FAQ page.


Medicaid Fraud Hotline: 888.742.7248 or Report Online
and claim reward