048-16 Wyo. Code R. §§ 16-10 - Investigation of Suspected Fraud, Waste, or Abuse of Services by Providers

(a) The Department shall be responsible for the detection of suspected fraud, waste, or abuse of services.

(b) The Department is authorized to investigate, or to refer to appropriate agencies the investigation of suspected fraud, waste, or abuse of services identified pursuant to this section. An investigation shall be for the purpose of determining if:

(i) The identified practice is lawful and in compliance with existing rules and regulations and state and federal laws;

(ii) Fraud, waste, or abuse of services exists and can be documented;

(iii) Sufficient evidence can be developed to support the recovery of overpayments, the imposition of an adverse action or any other civil or criminal action permitted by law; or

(iv) The matter should be referred for additional investigation or other action by a law enforcement agency or the Medicaid Fraud Control Unit (MFCU).

(c) The Department'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, or contractors;

(iii) Verification of a provider's professional credentials, the credentials of the provider's associates, agents, employees, or contractors;

(iv) Interviews with clients;

(v) Examination of equipment, supplies or other items used in a client's treatment;

(vi) Examination of prescriptions;

(vii) Random sampling and extrapolation; and

(viii) Examination of financial records, including, but not limited to, insurance claims or records, or records of any other source of payment.

(d) For purposes of performing its duties under this Chapter, the Department may use any relevant information necessary to conduct an investigation.

(e) 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;

(ii) Take adverse action against the provider; or

(iii) Refer the matter to law enforcement, the Wyoming Attorney General, Health and Human Services (HHS), Department of Family Services (DFS) Eligibility Integrity Unit, the MFCU, or other appropriate authorities for possible civil or criminal action.

Notes

048-16 Wyo. Code R. §§ 16-10

Amended, Eff. 4/30/2020.