Wyo. Code R. 048-0037-16
Medicaid
Chapter 16: Medicaid Program Integrity
Effective Date: 11/06/1990 to 07/05/1994
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.16.11061990
Date Filed 11/06/90 Expr Date Supr Date Repeal Date Document Type RULES
This rule is promulgated by the Department of Health pursuant to W. S. 42-4-101 et seq., and the Wyoming Administrative Procedures Act at W. S. 16-3-101 et seq.
(a) This Chapter shall apply to and govern the identification and investigation of suspected fraud, theft or abuse by providers; the identification and investigation of suspected fraud, theft or abuse by recipients; the recovery of excess payments; and the imposition of sanctions for any of the above activities.
(b) The Department may refer suspected provider or recipient fraud, theft or abuse to the appropriate law enforcement and/or Medicaid fraud control unit for the investigation of criminal activity.
(a) These rules are intended to implement and be read in conjunction with the provisions of applicable federal and state statutes and rules.
(b) The Department may issue Manuals or Bulletins to providers and/or other affected parties to interpret the provisions of this Chapter. Such Manuals and Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained Manuals or Bulletins shall be subordinate to the provisions of this Chapter.
(a) 'Abuse.' A pattern of practice by a provider or a recipient that results in health care utilization which is inconsistent with sound fiscal, business, or medical practices, and results in unnecessary costs to Medicaid, or in payment for
services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse is characterized by, but not limited to, any one of the following:
(i) The repeated submission of claims by a provider from which required material information is missing or incorrect. Examples include, but are not limited to: incorrect or missing procedure or diagnosis codes, incorrect mathematical entries,
July 1, 1994
incorrect third party liability information, or the incorrect use of procedure code modifiers;
(ii) The repeated submission of claims by a provider presenting procedure codes which overstate the level or amount of services provided;
(iii) The repeated submission of claims by a provider for services which are not reimbursable under Medicaid, or the repeated submission of duplicate claims;
(iv) Failure by a provider to develop and maintain legible medical records which document the nature, extent and evidence of the medical necessity of services provided;
(v) Failure of a provider to use generally accepted accounting principles, or other accounting methods which relate entries on the medical record to entries on the claim;
(vi) Excessive or inappropriate patterns of referral;
(vii) The repeated submission of claims by a provider for services which were not medically necessary;
(viii) The repeated submission of claims by a provider for services which exceed that requested or agreed to by the recipient or the recipient's responsible relative or guardian;
(ix) The submission of claims for services not medically necessary under the generally accepted practice of providers of such services;
(x) Overprescribing or misprescribing pharmaceutical products or other services;
(xi) The repeated submission of claims by a provider without complying with the provisions of Chapter 4;
(xii) A recipient permitting the use of the recipient's Medicaid identification card by any unauthorized individual for the purpose of obtaining services;
(xiii) A recipient obtaining services which are not medically necessary for the purpose of resale or for the use of a non-recipient; or
(xiv) A recipient obtaining duplicate services from more than one provider for the same medical condition, other than confirmation of a diagnosis, evaluation or assessment.
(b) 'Administrator.' The administrator of the division, the administrator's agent, designee or successor.
(c) 'Chapter 1.' Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(d) 'Chapter 4.' Chapter 4. Third Party Liability and
Medical Expense Recoveries, of the Wyoming Medicaid Rules.
(e) 'Chapter 8.' Chapter 8, Inpatient Hospital Certification, of the Wyoming Medicaid Rules.
(f) 'Claim.' A request by a provider for Medicaid payment for services provided to a recipient.
(g) 'Covered services.' Services which are Medicaid reimbursable pursuant to the rules of the Department.
(h) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(i) 'Department of Family Services (DFS).' the Wyoming Department of Family Services, its agent, designee or successor.
(j) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(k) 'Emergency.' A situation where the division has probable cause to believe:
(i) A provider is or has been engaged in criminal activity involving the Medicaid program;
(ii) That medical or financial records will be destroyed if advance notice of intent to review such records is provided; or
(iii) The mental or physical health or safety of recipients is in imminent danger.
(l) 'Equipment.' Durable medical equipment, including oxygen and oxygen supplies, that is:
(i) Able to withstand repeated use;
(ii) Primarily used to serve a medical purpose;
(iii) Generally not useful to a person in the absence of an illness or injury; and
(iv) Appropriate for home use.
(m) 'Excess payments.' Medicaid funds received by a provider:
(i) Which exceed the Medicaid allowable payment;
(ii) Which result from fraud, theft or abuse; or
(iii) Where third party liability, as defined in Chapter 4, is discovered and recovery is necessary.
(n) 'Financial records.' All records, in whatever form, used or maintained by a provider in the conduct of its business affairs and which are necessary to substantiate or understand claims submitted to the Department.
(o) 'Fiscal agent.' The Department's agent responsible for processing claims.
(p) 'Fraud.' An intentional deception or misrepresentation made by an individual with the knowledge that the deception or misrepresentation may result in excess payments. 'Fraud' includes any actions or inactions that constitute fraud under federal or state law.
(q) 'Generally Accepted Accounting Principles (GAAP).' Accounting concepts, standards and procedures established by the American Institute of Certified Public Accountants.
(r) 'Generally Accepted Auditing Standards (GAAS).' Auditing standards, practices, and procedures established by the American Institute of Certified Public Accountants.
(s) 'HCFA.' The Health Care Financing Administration of HHS, its agent, designee or successor.
(t) 'HHS.' The United States Department of Health and Human Services, its agent, designee or successor, including the office of Inspector General.
(u) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act of 1967, as amended.
(v) 'Medicaid allowable payment.' The maximum Medicaid reimbursement as determined pursuant to the rules of the Department.
(w) 'Medicaid fraud control unit.' A Medicaid fraud control unit established pursuant to the Social Security Act and applicable HCFA regulations.
(x) 'Medical records.' All records, in whatever form, in the possession of or subject to the control of a provider which describe the recipient's diagnosis, treatment or condition.
(y) 'Medical supplies.' Disposable, semi-disposable or expendable medical supplies.
(z) 'Medically necessary.' Except as otherwise defined by the rules of the Department, a service that is:
(i) Consistent with the recipient's diagnosis and condition;
(ii) Recognized as the prevailing standard or current practice among the provider's peer group;
(iii) Required to meet the medical needs of the recipient and is undertaken for reasons other than the convenience of the recipient or the provider of the services; and
(iv) Provided in the least costly setting required by the recipient's condition.
(aa) 'Medicare.' The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(bb) 'Misuse.' With respect to a recipient, the request for or utilization of services that are inappropriate. With respect to a provider, the furnishing of services that are inappropriate, or the submission of claims that do not accurately reflect the services provided.
(cc) 'MMIS.' The Medicaid Management Information System, as certified by HHS and implemented by the Department.
(dd) 'Pattern.' An identifiable series of events or activities.
(ee) 'Peer review.' The pre or post payment review of a provider's claims by one or more appropriately licensed or credentialed individuals to determine whether such claims reflect generally accepted practices.
(ff) 'Provider.' A provider as defined by Chapter 3, which definition is incorporated by this reference.
(gg) 'Provider agreement.' A written agreement between a provider and the Department in which the provider agrees to comply with the provisions of the provider agreement as a condition of receiving Medicaid payment for services provided to recipients.
(hh) 'Recipient.' A person who has been determined eligible for Medicaid.
(ii) 'Repeated submission.' The submission by a provider of more than two claims substantiating that an activity was performed by a recipient or a provider on more than two occasions.
(jj) 'Sanctions.' With respect to providers, the actions permitted by Section 9. With respect to recipients, the actions permitted by Section 16.
(kk) 'Services.' Health care services, medical supplies and equipment.
(ll) 'Suspension.' Making a Provider ineligible to receive Medicaid reimbursement for providing services for a specified period of time, or making a recipient ineligible for Medicaid for a specified period of time.
(mm) 'Suspension of payments.' The stoppage of all unpaid claims pending resolution of the matter in dispute between the provider and the Department.
(nn) 'Termination.' Making a provider indefinitely ineligible to receive Medicaid reimbursement for providing services, or making a recipient indefinitely ineligible for Medicaid.
(oo) 'Working day.' 8:00 a.m. to 5:00 p.m., Mountain Time, Monday through Friday, excluding State holidays.
(a) Record keeping requirements. Providers shall maintain medical records and financial records pursuant to the requirements of the Department's rules.
(b) Access to records. In addition to the requirements of the Department's rules, federal regulations and the provider agreement, providers shall grant access to medical records and financial records during regular business hours to the Department, DFS, HCFA, HHS and the Wyoming Attorney General, or any of their lawful agents or representatives, for purposes pertaining to administration of the Medicaid program, including, but not limited to, audit and identification and investigation of Medicaid fraud control unit pursuant to Sections 6 and 7 of these rules. Individuals seeking access to records shall furnish proper identification. Unless otherwise specified by the entity seeking access, the provider may provide access by permitting the review of the original records or by making legible copies available.
(i) Except in an emergency, the entity seeking access to medical or financial records shall mail written notice, by certified mail, return receipt requested, to the provider at least ten days before the date on which access is sought, specifying the date and time on which records are to be made available.
(ii) In an emergency, any entity authorized access by this Chapter and seeking access to medical or financial records may review such records during regular business hours without providing notice.
(c) Refusal to provide access. The refusal of a provider to make financial or medical records available upon request pursuant to this section shall result in the immediate suspension of all Medicaid payments made to the provider for the services under audit. All Medicaid payments made to the provider during the fiscal year for the services under audit shall be repaid to the Department within ten days after written request from the Department.
(d) Copying records.
(i) The Department, or any of the agencies entitled to access to records pursuant to Subsection (b), is authorized to copy, at its own expense, any medical or financial records to which it has access pursuant to this section or any other rules of the Department. Copying shall be done at the provider's premises, unless otherwise authorized in writing by the provider.
(ii) Copies furnished by a provider. Reimbursement for copying done by a provider shall be the greater of ten cents per legible page or $1.00 per patient record.
(e) Confidentiality of records. The Department shall comply with the provisions of 42 C.F.R. Part 41, Subpart F, and W.S. 42-4-112 regarding the confidentiality of records.
(a) The Department shall be responsible for the detection of suspected fraud, theft, abuse, presentment of false or duplicate claims, presentment of claims for services not medically necessary, or false statement or representation of material facts by providers.
(b) Sources of information. For purposes of performing its duties under this rule, the Department may use information from sources including, but not limited to:
(i) Units of state, local or the federal government;
(ii) Other third-party payers of health services, including health insurance carriers;
(iii) Professional review organizations;
(iv) Individuals, including recipients;
(v) Computer reports based on Medicaid claims data generated by the Department, MMIS or the fiscal agent; or
(vi) Contractors hired by the Department to assist in the administration of the Medicaid program.
Section 7. Investigation of suspected fraud or abuse by providers.
(a) The Department is authorized to investigate, or to refer to appropriate agencies for investigation, suspected fraud or abuse identified pursuant to Section 6. An investigation shall be for the purpose of determining whether:
(i) The identified practice is legitimate;
(ii) Fraud or abuse exists and can be documented;
(iii) Sufficient evidence can be developed to support the recovery of excess payments, the imposition of sanctions or any other civil or criminal action permitted by law; and/or
(iv) The matter should be referred for additional investigation or other action by a law enforcement agency or Medicaid fraud control unit.
(b) The Department's investigation may include, but is not limited to:
(i) Examination of medical or financial records;
(ii) Interviews of providers, their associates, agents or employees;
(iii) Verification of a provider's professional credentials, the credentials of the provider's associates, agents or employees, or both;
(iv) Interviews with recipients;
(v) Examination of equipment, supplies or other items used in a recipient's treatment;
(vi) Examination of prescriptions;
(vii) Random sampling;
(viii) Determination of whether the services provided were medically necessary; and (ix) Examination of insurance claims or records, or records of any other source of payment.
(c) Post-investigation actions. After the completion of an investigation, the Department shall take one or more of the following actions:
(i) Determine that no further action is warranted and notify the provider in writing of that determination:
(ii) Recover excess payments;
(iii) Impose sanctions; and/or
(iv) Refer the matter to the Wyoming Attorney General, HHS, a Medicaid fraud control unit or other appropriate authorities for possible civil or criminal action.
(a) Grounds. The Department is authorized to recover excess payments from providers which result from:
(i) Fraud, theft or abuse;
(ii) A pattern of presenting false or duplicate claims or claims for services not medically necessary;
(iii) A pattern of making false statements of material facts; or
(iv) The receipt of Medicaid funds in excess of the Medicaid allowable payment established by the Department.
(b) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice, by certified mail, return receipt requested, to the provider. The notice shall include:
(i) The amount of the excess payments;
(ii) The basis for the determination of excess payments;
(iii) The provider's rights to request reconsideration of that determination pursuant to Section 18; and
(iv) That the failure to request reconsideration shall preclude any further appeal of the decision to recover excess payments.
(c) Reimbursement of excess payments. A provider must reimburse the Department for excess payments within 30 days after he provider receives written notice from the Department of the excess payments. Neither the filing of a request for reconsideration nor a request for an administrative hearing shall stay the effective date of the adverse action. The provider may request a stay by filing a written request with the Administrator. Such request must be filed on or before the due date of the request for reconsideration. The Administrator shall grant a stay if the Administrator determines that the issuance of a stay is necessary to protect the provider from suffering irreparable harm, and may issue a stay upon such conditions as the Administrator finds are necessary. The Administrator shall send written notice to the provider of his decision regarding a request for a stay. Such notice shall be sent by certified mail, return receipt requested, and shall include findings of fact in support of the decision.
(d) Methods of recovery of excess payments. If a provider does not timely reimburse the Department, and no stay has been issued pursuant to (c), the Department may recover the excess payments by:
(i) Withholding all or part of Medicaid payments until the excess payments are recovered;
(ii) Initiating a civil lawsuit against the provider; or
(iv) Any other method of collecting a debt or obligation permitted by law.
(f) Recovery from a clinic, group, corporation, professional association or other organization. The Department may recover excess payments from a clinic, group, corporation, professional association or other organization which resulted from fraud or abuse of any current or former member of that practice.
(g) Recovery from individual. The Department may recover excess payments from an individual provider that was formerly part of a clinic, group, corporation, professional association or other organization which committed fraud or abuse.
(a) Available sanctions.
(i) After the completion of an investigation, the Department is authorized to impose any of the following sanctions following a determination that a provider has engaged in abuse:
(A) Educational intervention;
(B) Recovery of excess payments pursuant to Section 8;
(C) Postpayment review of all claims submitted by the provider;
(D) Prepayment review of all claims submitted by the provider;
(E) Referral to the appropriate state regulatory agency, licensing agency or Medicaid
fraud control unit;
(F) Peer review;
(G) Suspension;
(H) Termination; or
(I) Condition future participation upon the provider's agreement to a conditional provider agreement which:
(I) Is for a limited duration; or
(II) Establishes specific conditions of participation.
(ii) The Department is authorized to impose any of the following sanctions following a determination that a provider has engaged in fraud or theft or has been convicted of a crime related to the provider's participation in Medicaid or Medicare:
(A) Recovery of excess payments pursuant to Section 8;
(B) Suspension; or
(C) Termination.
(b) Decision to impose sanctions. The decision to impose sanctions on a provider shall be made by the Administrator of the Division. The Administrator shall consider:
(i) The nature and extent of the provider's violations;
(ii) The provider's history of previous violations;
(iii) Actions taken or recommended by other state regulatory or licensing agencies; and
(iv) The steps taken by the provider to reduce the possibility of future violations.
(c) Grounds. The Department is authorized to impose sanctions on a provider for:
(i) Fraud, theft or abuse in submitting claims;
(ii) A pattern of presenting false or duplicate claims or claims for services not medically necessary;
(iii) A pattern of making false statements of material facts for the purpose of obtaining excess payments; or
(iv) Refusal to grant access pursuant to Section 5.
(d) Notice of sanctions. After determining to impose sanctions on a provider, the Department shall, within ten working days after the decision, send written notice to the provider by certified mail, return receipt requested. The notice shall include:
(i) The proposed sanction;
(ii) The effective date of the proposed sanction;
(iii) The basis for the determination to impose the sanction;
(iv) The provider's rights to request reconsideration of that determination pursuant to Section 18; and
(v) That the failure to request reconsideration shall preclude any further appeal of the decision to impose sanctions.
(e) Effective date of sanction.
(i) The sanctions specified in subparagraphs (a)(i)(A) through (F) and a(ii)(A) shall be effective upon the Department's determination to impose such sanctions.
(ii) The sanctions specified in subparagraphs (a)(i)(G) through (I) and a(ii)(B) and (C) shall be effective on the date specified in the notice of sanction sent pursuant to subsection (d), except that:
(A) If a provider requests reconsideration pursuant to subsection 17(a), the sanction shall not be effective until the time within which to request an administrative hearing pursuant to subsection 17(c) has expired; and
(B) If a provider requests an administrative hearing pursuant to subsection 17(c), the sanction shall not be effective until the date the Department issues a final decision after the hearing.
(f) Effect of suspension or termination.
(i) A provider suspended or terminated shall not submit any claims, either personally or through a business agent, clinic, group or other association, for any services provided after the effective date of the suspension or termination; and
(ii) No clinic, group, corporation, professional association or other organization shall submit any claim for services provided by an individual provider within such organization after the effective date of the individual provider's suspension or termination.
(iii) The Department shall not pay any claims submitted by a provider for services provided to a recipient after the effective date of termination or during any period of suspension.
(g) Notice of sanctions. After one of the sanctions specified in subparagraphs (a)(i)(E) through (I) or (a)(ii)(B) or (C) has been imposed, and after all administrative and judicial appeals and any applicable appeal periods have been exhausted, the Department shall send written notice to the appropriate professional society, the appropriate state licensing agency and HCFA. Such notice shall include the sanction, the findings of fact which led to the sanction and the results of any appeals.
(h) Reinstatement. No provider that has been suspended or terminated shall be reinstated as a Medicaid provider until:
(i) The provider has reimbursed the Department for all excess payments;
(ii) The Department is satisfied that sufficient safeguards have been installed to insure that the fraud or abuse which led to the suspension or termination will not recur.
(i) No obligation to reinstate. The Department shall not be obligated to reinstate a terminated provider or to reinstate a suspended provider prior to the end of the period of suspension even if the requirements of subsection (h) are satisfied.
(a) The remedies provided by this rule are cumulative. The Department may simultaneously seek to recover excess payments, impose sanctions and refer the matter to the appropriate law enforcement agencies for criminal action. Nothing in this rule shall preclude the Department from pursuing any remedies permitted by other provisions of state and federal statutes or rules.
(b) Routine audits. Nothing in this rule shall prohibit the Department from conducting routine audits of providers as required or permitted by federal or state laws or policies.
(a) Automatic suspension or termination. The Department shall suspend or terminate any provider who has been suspended or terminated from participation in Medicare.
(b) Duration of suspension or termination. The duration of the provider's suspension or termination from participation in Medicaid shall be the same as and shall run contemporaneously with the provider's suspension or termination form participation in Medicare.
(c) No separate appeal. A provider suspended or terminated from participation in Medicaid pursuant to this section shall not be entitled to reconsideration or an administrative hearing pursuant to this rule or any other rules of the Department. The provider's remedies are limited to those provided by Medicare.
(a) Authorization. The Department may recover excess payments based upon extrapolation from systematic random samples of claims submitted by a provider and paid by Medicaid.
(b) Determination to use sampling. The determination to use sampling shall be within the Department's discretion. Sampling may be used when one or more of the following exists:
(i) The claims to be sampled represent services to fifty or more recipients; or
(ii) The claims to be sampled represent charges to the Department of more than $500.00.
(c) Sampling methods. The Department shall adhere to the following standards in using sampling:
(i) Samples shall be selected using a method which ensures that each claim in the universe to be sampled has an equal and independent chance of being chosen for the sample;
(ii) Samples shall be selected only from claims within a time period which coincides with the period under investigation and from which recovery may be made;
(iii) The sampling method, including the size of the sample, the selection of the samples and any extrapolation from the results of the sample, shall be in accordance with statistical procedures published in the following texts, which are incorporated by reference: L. Kish, Survey Sampling, John Wiley and Sons, New York (1965), or W. Cochran, Sampling Techniques, John Wiley and Sons, New York (3d ed. 1977). The books are available from the publishers; and
(iv) Samples shall be selected at the 95 percent confidence level. Recovery shall be the extrapolated amount less five percent.
(d) Notice of intent to sample. The Department shall notify the provider of its intent to use sampling and extrapolation. The notice shall include:
(i) The nature of the claims to be sampled;
(ii) The number of claims from which the sample will be selected;
(iii) The number of claims to be selected for the sample;
(iv) The method to be used in selecting the sample; and
(v) The method to be used in extrapolating from the sample.
(e) Effect of sampling results. The amount of excess payments determined pursuant to sampling shall be rebuttably presumed to be correct. The provider may rebut the presumption by providing, at the provider's expense, a complete audit using GAAS, or by demonstrating that the method used by the Department failed to comply with the requirements of this Section.
Section 13. Suspending or withholding payments pending reconsideration or administrative hearing. The Department may suspend or withhold payments for services furnished by a provider pending reconsideration or administrative hearing if the Administrator determines that:
(a) There is a substantial likelihood the Department will prevail in an action to recover excess payments;
(b) There is a substantial likelihood the provider's pattern or practice which prompted the investigation will continue; or
(c) There is reasonable cause to doubt the provider's financial ability to refund any excess payments.
(d) The decision to suspend or withhold payments pursuant to this section shall not be subject to reconsideration pursuant to this rule or an administrative hearing pursuant to Chapter 1.
recipients.
(a) The Department is authorized to identify and investigate suspected fraud, theft or abuse by recipients.
(b) Sources of information. For purposes of its duties under this rule, the Department may use information from sources including, but not limited to those specified in Section 6.
Section 15. Investigation of suspected fraud or abuse by recipients.
(a) The Department is authorized to identify and investigate suspected fraud or abuse identified pursuant to Section 14. An investigation shall be for the purpose of determining whether:
(i) Fraud or abuse exists and can be documented;
(ii) Sufficient evidence can be developed to support restricting recipient participation pursuant to section 16; or
(iii) Sufficient evidence can be developed to support the imposition of sanctions or any other civil or criminal action permitted by law.
(b) Post-investigation actions. After the completion of an investigation, the Department shall take one or more of the following actions:
(i) Determine that no further action is warranted and notify the recipient in writing of that determination;
(ii) Impose sanctions; or
(iii) Refer the matter to the Wyoming Attorney General, DFS, or another appropriate law enforcement agency for possible civil or criminal action.
Section 16. Imposition of sanctions on recipients.
(a) Available sanctions. The Department is authorized to impose any of the following sanctions following a determination that a recipient has engaged in conduct proscribed by this Chapter:
(i) Refer the recipient to mandatory counselling to correct inappropriate or dangerous utilization of services;
(ii) Recover excess payments from the recipient, to the extent permitted by law;
(iii) Refer the matter to the Wyoming Attorney General, DFS, HHS, a Medicaid fraud control unit or other appropriate entity to investigate suspected criminal activity;
(iv) Terminate the recipient's participation in Medicaid during any period in which the recipient refuses to sign a consent for the release of medical or financial records;
(v) Restrict the recipient's future participation in Medicaid to receiving services from the provider or providers designated by the Department. Medicaid payments shall be limited to the designated provider, except for payments for emergency care; or
(vi) Suspend or terminate the recipient's participation in Medicaid if the recipient made misrepresentations of fact on his or her application for Medicaid, or if the recipient has resold or otherwise transferred services to a third party.
(b) Decision to impose sanctions. The decision to impose sanctions on a recipient shall be made by the Administrator. The Administrator shall consider, among other things:
(i) The nature and extent of the recipient's violations; and
(ii) The recipient's history of previous violations.
(c) Grounds. The Department may impose sanctions on a recipient for:
(i) Fraud, theft or abuse in obtaining services;
(ii) Alteration or duplication of the recipient's Medicaid identification card;
(iii) Permitting, authorizing or assisting a non-recipient to use the recipient's Medicaid identification card to obtain services;
(iv) Using another recipient's Medicaid identification card to obtain services;
(v) Alteration or duplication of a prescription;
(vi) Knowingly misrepresenting material facts regarding the recipient's physical or mental condition for the purpose of obtaining services;
(vii) Knowingly furnishing incorrect information regarding eligibility to a provider;
(viii) Knowingly furnishing incorrect information to a provider to obtain services which are not medically necessary; or
(ix) Obtaining services by any false or incorrect pretenses.
(d) Notice of sanctions. After determining to impose sanctions on a recipient, the Department shall send written notice to the recipient by certified mail, return receipt requested. The notice shall include:
(i) The proposed sanction; (ii) The effective date of the proposed sanction; (iii) The basis for the determination to impose the sanction; (iv) The recipient's right to request an administrative hearing pursuant to Chapter 1; and (v) That the failure to request an administrative hearing shall preclude any further appeal of the proposed sanction.
Section 17. Misuse.
(a) As part of its responsibilities pursuant to this Chapter, the Department may investigate whether a provider or recipient has misused the Medicaid program. Such investigations shall be conducted pursuant to Section 7 or Section 15, as appropriate.
(b) If the Department determines that a provider has misused the Medicaid program, it may:
(i) Refer the matter to the appropriate entity for further action; and/or (ii) Request that the provider participate in provider education, to be furnished by the Department.
(c) If the Department determines that a recipient has misused the Medicaid program, it may:
(i) Refer the matter to the appropriate entity for further action; and/or (ii) Request that the recipient participate in recipient education, to be furnished by the Department.
(d) If the Department determines to ask a provider or recipient to participate in appropriate education, it shall provide written notice to the individual or entity, by certified mail, return receipt requested, setting forth:
(i) The reason(s) for the request; (ii) The educational program(s) available; (iii) The time and date of such program(s); (iv) That participation in such program(s) is voluntary; and (v) Non-participation in such program(s) shall not affect Medicaid program participation.
(e) The determination of misuse pursuant to this Section and the decision to proceed pursuant to (b) or (c) shall not preclude the Department from taking other action as allowed by this Chapter or other appropriate laws.
(a) Request for reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or impose sanctions. Such request must be mailed to the Department by certified mail within twenty days after the date the provider receives notice pursuant to Sections 8 or 9.
(b) Reconsideration. The Department shall review the decision and send written notice to the provider of its final decision within forty-five days after receipt of the request for reconsideration. The Department may request additional information from the provider as part of the reconsideration process.
(c) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter 1 by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days after the date the provider receives notice of the final decision. The request for hearing must meet the requirements of Chapter 1.
(d) Failure to request reconsideration. A provider that fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing regarding the decision to recover excess payments or impose sanctions pursuant to Chapter 1.
Section 19. Delegation of duties. The Department may delegate any of its duties under this rule to the Wyoming Attorney General, HHS, any other agency of the federal, state or local government, or a private entity which is capable of performing such functions, provided that the Department shall retain the authority to impose sanctions, recover excess payments or take any other final action authorized by this Chapter.
Section 20. Superseding effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including Provider Manuals and/or Provider Bulletins, which are inconsistent with this Chapter.
Section 21. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
The Wyoming Department of Health (the Department) is the single state agency appointed pursuant to the Social Security Act (the Act) to administer the Medicaid program in Wyoming. The Wyoming Medical Assistance and Services Act of 1967 (the Wyoming Act) requires the Department to administer the Medicaid program in conformance with federal standards. The Health Care Financing Administration of the United States Department of Health and Human Services (HCFA) is the federal agency responsible for administering the Medicaid program.
The Act and HCFA regulations require the Department to ensure the integrity of the Wyoming Medicaid Program through a process of surveillance and utilization review, including methods and criteria for identifying and investigating suspected theft, fraud or abuse by providers of services or recipients of services. If there has been theft, fraud or abuse, the Department is to recover incorrect payments, impose sanctions, or refer the matter to the appropriate authorities for potential civil or criminal actions. The Department's methods and criteria must ensure due process of law to providers and recipients.
The existing Chapter XVI was promulgated to establish the legal framework for the surveillance and utilization review of providers and recipients of Medicaid services in conformance with federal law. Chapter 16 is being amended to clarify those methods and standards, while ensuring protection of the due process rights of providers and recipients.
July 1, 1994