Wyo. Code R. 048-0037-16
Medicaid
Chapter 16: Medicaid Program Integrity
Effective Date: 12/16/1998 to 11/07/2011
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.16.12161998
This Chapter 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 overpayments; and the imposition of sanctions for any of the above activities.
(b) The Division 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) This Chapter is intended to implement and be read in conjunction with the provisions of applicable federal and state statutes and rules, including Chapter 39.
(b) The Division 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 in 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, missing signatures, incorrect mathematical entries, 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 coupon 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;
(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; or
(xv) Misuse.
“Administrator.” The administrator of the Division, the administrator’s agent, designee or successor.
“Adverse action.” “Adverse action” as defined in Chapter 1, which definition is incorporated by this reference.
“Chapter 1.” Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
“Chapter 2. Chapter 2, State Licensed Shelter Care Eligibility and Services, of the Wyoming Medicaid Rules.
(f) 'Chapter 4.' Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.
(g) 'Chapter 8.' Chapter 8, Inpatient Hospital Certification, of the Wyoming Medicaid Rules.
(h) 'Chapter 38.' Chapter 38, Safeguarding Information on Applicants and Recipients, of the Wyoming Medicaid Rules.
(i) 'Chapter 39.' Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.
(j) 'Claim.' A request by a provider for Medicaid payment for services provided to a recipient.
(k) 'Covered services.' Services which are Medicaid reimbursable pursuant to the rules of the Department.
(l) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(m) 'Department of Family Services (DFS).' the Wyoming Department of Family Services, its agent, designee or successor.
(n) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(o) 'Educational program.' Provider training by the Division regarding covered services, Division policies, and/or proper submission of claims.
(p) '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 or altered 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.
(q) '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.
(r) “Excess payments.” “Excess payments” as defined in Chapter 39, which definition is incorporated by this reference.
(s) “Federal Medicaid funds.” Federal funds paid by HHS to the State pursuant to 42 U.S.C. § 1396b(d) and subsequently paid to a provider.
(t) “Federal Medicaid Percentage (FMAP).” “Federal medical assistance percentage” as defined in 42 U.S.C. § 1396d(b), which definition is incorporated by this reference.
(u) “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.
“Fiscal agent.” The Department’s agent responsible for processing claims.
(w) “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.
(x) “Generally Accepted Accounting Principles (GAAP).” Accounting concepts, standards and procedures established by the American Institute of Certified Public Accountants.
(y) “Generally Accepted Auditing Standards (GAAS).” Auditing standards, practices, and procedures established by the American Institute of Certified Public Accountants.
“HCFA.” The Health Care Financing Administration of HHS, its agent, designee or successor.
(aa) “HHS.” The United States Department of Health and Human Services, its agent, designee or successor, including the Office of Inspector General.
(bb) “Medicaid.” Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act of 1967, as amended. “Medicaid” includes any successor or replacement program enacted by Congress or the Wyoming Legislature.
“Medicaid allowable payment.” The maximum Medicaid reimbursement as determined pursuant to the rules of the Department.
(dd) “Medicaid Fraud Control Unit (MFCU).” The Medicaid Fraud Control Unit of the Wyoming Attorney General’s Office, its agent, designee, or successor.
(ee) “Medicaid funds.” That combination of Federal Medicaid funds and State Medicaid funds that is available to the Division to make payments to providers. The federal portion shall be the FMAP. The state portion shall be the State Medicaid percentage.
(ff) “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.
(gg) “Medical supplies.” Disposable, semi-disposable or expendable medical supplies.
(hh) “Medically necessary.” “Medically necessary” as defined in Chapter 3, which definition is incorporated by this reference.
(ii) “Medicare.” The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(jj) “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.
(kk) “MMIS.” The Medicaid Management Information System, as certified by HHS and implemented by the Department.
(ll) “Overpayment.” “Overpayment” as defined in Chapter 39, which definition is incorporated by this reference.
(mm) “Patient record.” All documentation in a provider’s possession or control, including financial and/or medical records, which relates to:
(nn) “Pattern.” An identifiable series of events or activities.
(oo) “Prepayment or postpayment review.” The prepayment or postpayment review of a provider’s claims by the Division to determine whether such claims reflect generally accepted practices.
(pp) “Provider.” A provider as defined by Chapter 3, which definition is incorporated by this reference.
(qq) “Provider agreement.” Provider agreement as defined in Chapter 3, which definition is incorporated by this reference.”
(rr) “Recipient.” A person who has been determined eligible for Medicaid.
(ss) “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.
(tt) “Sanctions.” With respect to providers, the actions permitted by Section 9. With respect to recipients, the actions permitted by Section 16.
(uu) “Services.” Health care services, medical supplies , or equipment.
(vv) “State Medicaid funds.” The dollar amount of the state general funds appropriated by the Wyoming Legislature for the Medicaid program which constitutes the State Medicaid percentage.
(ww) “State Medicaid percentage.” The state percentage as determined pursuant to 42 U.S.C. § 1396d(b).
(xx) “Suspension.” Making a Provider ineligible to receive Medicaid reimbursement for providing covered services for a specified period of time, or making a recipient ineligible for Medicaid for a specified period of time.
(yy) “Suspension of payments.” The stoppage of all unpaid claims pending resolution of the matter in dispute between the provider and the Division.
(zz) “Termination.” Making a provider indefinitely ineligible to receive Medicaid reimbursement for providing covered services, or making a recipient indefinitely ineligible for Medicaid.
(aaa) “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 record keeping requirements of Chapter 3, which are incorporated by this reference, and pursuant to other applicable provisions of the Department’s rules. A provider’s failure to comply with program record keeping requirements shall result in the denial or recoupment of payments.
(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 Division, DFS, HCFA, HHS, MFCU, 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 fraud pursuant to Sections 6 and 7 of this Chapter. 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 on-site access to medical or financial records shall mail written notice, by certified mail, return receipt requested, to the provider at least ten calendar 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 to the provider for the services under audit. All Medicaid payments to the provider during the fiscal year for the services under audit shall be repaid to the Division within ten days after written request from the Division.
(d) Copying records.
(i) The Division, 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) Request for patient records. The Division may request that a provider provide copies of patient records. The requested records shall be furnished to the Division within twenty working days after the date of the notice. The failure to timely provide complete patient records as requested shall be deemed to be a refusal to provide access and shall result in the suspension of payments and repayment of funds as specified in subsection 5(c).
(iii) Copies furnished by a provider. Reimbursement for copying done by a provider at the request of the Division shall be:
(D) A provider which seeks reimbursement for copy expenses shall submit an invoice to the Division with the requested records.
(e) Confidentiality of records. The Department shall comply with the provisions of 42 C.F.R. Part 431, Subpart F, W.S. § 42-4-112, and Chapter 38 regarding the confidentiality of records.
Section 6. Identification of suspected fraud, theft, or abuse.
(a) The Division 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 Chapter, the Division may use information from sources including, but not limited to:
(v) Computer reports based on Medicaid claims data generated by the Division, MMIS or the fiscal agent; or
(vi) Contractors hired by the Division to assist in the administration of the Medicaid program.
(a) The Division is authorized to investigate, or to refer to appropriate agencies for investigation, suspected fraud, theft, 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, theft, or abuse exists and can be documented;
(iii) Sufficient evidence can be developed to support the recovery of overpayments, 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 MFCU.
(b) The Division’s investigation may include, but is not limited to:
(i) Examination of medical, financial, or patient 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 Division shall take one or more of the following actions:
(i) Determine that no further action is warranted;
(ii) Recover excess payments pursuant to Chapter 39;
(iii) Recover overpayments pursuant to Section 8;
(iv) Impose sanctions; and/or
(v) Refer the matter to the Wyoming Attorney General, HHS, the MFCU, or other appropriate authorities for possible civil or criminal action.
(a) Grounds. The Division shall recover overpayments.
(b) Notice of overpayments. After determining that a provider has received overpayments, the Division shall send written notice, by certified mail, return receipt requested, to the provider. The notice shall include:
(i) The amount of the overpayments;
(ii) The basis for the determination of overpayments;
(iii) The provider’s rights to request reconsideration of that determination pursuant to Section 17; and
(iv) That the failure to request reconsideration shall preclude any further appeal of the decision to recover overpayments.
(c) Reimbursement of overpayments. A provider must reimburse the Division for overpayments within 30 days after the provider receives written notice from the Division of the overpayments. Neither the filing of a request for reconsideration nor a request for an administrative hearing shall stay the effective date of the adverse action.
(d) Methods of recovery of overpayments. If a provider does not timely reimburse the Division, the Division shall recover the overpayments by:
(i) Withholding all or part of Medicaid payments until the overpayments are recovered;
(ii) Initiating a civil lawsuit against the provider; or
(iii) Any other method of collecting a debt or obligation permitted by law.
(e) Recovery from a clinic, group, corporation, professional association or other organization. The Division may recover overpayments from a clinic, group, corporation, professional association or other organization which resulted from fraud, theft, or abuse of any current or former member of that practice.
(f) Recovery from individual. The Division may recover overpayments from an individual provider that was formerly part of a clinic, group, corporation, professional association or other organization which committed fraud, theft, or abuse.
(g) Recovery of excess payments. The Division may recover excess payments pursuant to Chapter 39.
(a) Educational intervention.
(i) If the Division determines that a provider’s claims are not being submitted properly, or that a provider has engaged in abuse, fraud, or theft, the Division may require the provider to participate in and complete an educational program.
(ii) If the Division decides that a provider should participate in an educational program, it shall provide written notice to the provider, by certified mail, return receipt requested, setting forth:
(A) The reason(s) for the educational program;
(B) The educational program available;
(C) The time and date of such program; and
(D) That continued participation as a provider in Medicaid is contingent upon completion of the specified educational program.
(iii) An educational program may be presented by the Division and shall provide instruction in the correct submission of claims, the appropriate utilization of services, and/or such other problems as are identified by the Division. A provider that is asked to participate in an educational program and refuses, shall be suspended from participation in Medicaid until such time as the provider completes the required program. A request to participate in an educational program is not an adverse action and is not subject to reconsideration and/or an administrative hearing.
(b) Available sanctions.
(i) After the completion of an investigation, the Division is authorized to impose any of the following sanctions following a determination that a provider has engaged in abuse:
(A) Recovery of overpayments pursuant to Section 8;
(B) Recovery of excess payments pursuant to Chapter 39;
(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 MFCU;
(F) Suspension;
(G) Termination; or
(H) 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 Division 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 overpayments pursuant to Section 8;
(B) Recovery of excess payments pursuant to Chapter 39;
(C) Suspension; or
(D) Termination.
(c) 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.
(d) Grounds. The Division 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 overpayments ; or
(iv) Refusal to grant access pursuant to Section 5.
(e) Notice of sanctions. After determining to impose sanctions on a provider, the Division 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 17; and
(v) That the failure to request reconsideration shall preclude any further appeal of the decision to impose sanctions.
(f) Effective date of sanction.
(i) The sanctions specified in subparagraphs (b)(i)(A) through (E) and (b)(ii)(A) and (B) shall be effective upon the Division's determination to impose such sanctions.
(ii) The sanctions specified in subparagraphs (b)(i) (F) through (H) and (b)(ii) (C) and (D) shall be effective on the date specified in the notice of sanction sent pursuant to subsection (e), 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(g) has expired; and
(B) If a provider requests an administrative hearing pursuant to subsection 17(g), the sanction shall not be effective until the date the Department issues a final decision after the hearing.
(g) 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 Division 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.
(h) Notice of sanctions. After one of the sanctions specified in subparagraphs (b)(i) (F) through (H) or (b)(ii) (C) or (D) has been imposed, and after all administrative and judicial appeals and any applicable appeal periods have been exhausted, the Division 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.
(i) Reinstatement. No provider that has been suspended or terminated shall be reinstated as a Medicaid provider until:
(i) The provider has reimbursed the Division for all overpayments ;
(ii) The Division is satisfied that sufficient safeguards have been installed to insure that the fraud, theft, or abuse which led to the suspension or termination will not recur.
(j) No obligation to reinstate. The Division 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 9(i) are satisfied.
(a) The remedies provided by this Chapter are cumulative. The Division may simultaneously seek to recover overpayments, impose sanctions, take action pursuant to Chapter 39, and refer the matter to the appropriate law enforcement agencies, and/or MFCU for criminal action. Nothing in this Chapter shall preclude the Division 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 Division from conducting routine audits of providers as required or permitted by federal or state laws or policies.
(a) Automatic suspension or termination. The Division shall suspend or terminate any provider who has been suspended or terminated from participation in Medicare, or any provider which voluntarily withdraws from Medicare when Medicare certification is a prerequisite to enrollment in Medicaid.
(b) Duration of suspension or termination. The duration of the provider's suspension, termination, or withdrawal from participation in Medicaid shall be the same as and shall run contemporaneously with the provider's suspension, termination, or withdrawal from 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 Division may recover overpayments 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 Division'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 Division 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 Division 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 overpayments 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 Division failed to comply with the requirements of this Section.
Section 13. Suspending or withholding payments pending reconsideration or administrative hearing. The Division 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 Division will prevail in an action to recover overpayments ;
(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 overpayments.
(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.
(a) The Division is authorized to identify and investigate suspected fraud, theft or abuse by recipients.
(b) Sources of information. For purposes of its duties under this Chapter, the Division may use information from sources including, but not limited to those specified in Section 6.
(c) Referral of suspected fraud, theft, or abuse. The Division may, at any time, refer suspected recipient fraud, theft, or abuse, to DFS, the MFCU, or any other appropriate law enforcement agency.
(a) The Division is authorized to identify and investigate suspected fraud, theft, or abuse identified pursuant to Section 14. An investigation shall be for the purpose of determining whether:
(i) Fraud, theft, 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 recovery pursuant to Chapter 39 of excess payments or overpayments.
(b) Post-investigation actions. After the completion of or during an investigation, the Division shall take one or more of the following actions:
(i) Determine that no further action is warranted;
(ii) Take action pursuant to Section 16; or
(iii) Refer the matter to the Wyoming Attorney General, MFCU, DFS, or another appropriate law enforcement agency for possible civil or criminal action.
(a) Available actions. The Division is authorized to take any of the following actions after a determination that a recipient has engaged in conduct proscribed by this Chapter:
(i) Refer the recipient to counselling to correct inappropriate or dangerous utilization of services;
(ii) Recover overpayments from the recipient, to the extent permitted by law;
(iii) Restrict the recipient’s future participation in Medicaid to receiving services from the provider or providers designated by the Division. Medicaid payments shall be limited to the designated provider, except for payments for emergency care.
(b) Decision to impose sanctions. The decision to take action pursuant to this Section shall be made by the Division. The Division 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 for referral. The Division may refer a recipient pursuant to subsection 14(c) for:
(i) Fraud, theft or abuse in obtaining services;
(ii) Alteration or duplication of the recipient’s Medicaid identification coupon;
(iii) Permitting, authorizing or assisting a non-recipient to use the recipient’s Medicaid identification coupon to obtain services;
(iv) Using another recipient’s Medicaid identification coupon 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 action. After determining to take action regarding a recipient, the Division shall send written notice to the recipient by certified mail, return receipt requested. The notice shall include:
(i) The Division’s action;
(ii) The effective date of the Division’s action; and
(iii) The basis for the determination to take action.
(e) An action taken pursuant to this Section is not an adverse action pursuant to Chapter 1.
(a) Request for reconsideration.
(i) A provider may request that the Division reconsider a decision to recover overpayments or impose sanctions. Such request must be mailed to the Division by certified mail within twenty days after the date the provider receives notice pursuant to Sections 8 or 9. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(ii) An applicant or recipient may request that the Division reconsider a decision to recover overpayments. Such request must be mailed to the Division by certified mail, return receipt requested, within twenty days of the date the individual receives notice pursuant to Section 16.
(b) Reconsideration. The Division shall review the decision and send written notice by certified mail, return receipt requested, to the party requesting reconsideration of its final decision within forty-five days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.
(c) Request for additional information. The Division may request additional information from the party requesting reconsideration as part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The party to whom the request is directed must provide the requested information within thirty days after the date of the request. Failure to provide the requested information shall result in the dismissal of the request for reconsideration with prejudice.
(d) Matters subject to reconsideration. Reconsideration shall be limited to whether the Division has complied with the provisions of this Chapter and/or other applicable rules of the Department.
(e) Informal resolution. The party requesting reconsideration or the Division may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part of a subsequent administrative hearing or judicial proceeding.
(f) Failure to request reconsideration.
(i) A provider that fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing pursuant to Chapter 1 regarding the decision to recover excess payments or impose sanctions.
(ii) A recipient or applicant may elect not to request reconsideration and may request an administrative hearing pursuant to Chapter 1 regarding the overpayment. Such a request for hearing shall be made by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department within thirty days of the date of the notice of the adverse action.
(g) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter 1 by mailing by certified mail, return receipt requested, 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. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(h) Confidentiality of settlement agreements. If the Division and a provider enter into a settlement agreement as part of a reconsideration or an administrative hearing, such agreement shall be confidential, except as otherwise provided by law. A breach of confidentiality by the provider shall, at the Division's option, result in the settlement agreement becoming null and void.
(a) Federal Medicaid funds. The Division shall, in accordance with the Social Security Act and applicable HHS regulations, repay all recovered Federal Medicaid funds to HCFA.
(b) State Medicaid funds. The Division shall retain the State Medicaid percentage of all recovered Medicaid funds as a state general fund reduction.
Section 19. Delegation of duties. The Division 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 Division shall retain the authority to impose sanctions, recover excess payments or take any other final action authorized by this Chapter.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of its various provisions.
Section 21. 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 22. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in full force and effect.